Comparing Leadership Skills of Senior Emergency Medicine Residents in 3-Year Versus 4-Year Programs During Simulated Pediatric Resuscitation: A Pilot Study.

OBJECTIVES: The majority of pediatric patients in the United States (US) are evaluated and treated at general emergency departments. It is possible that discrepancies in length of emergency medicine (EM) residency training may allow for variable exposure to pediatric patients, critical resuscitations, and didactic events. The goal of this pilot study was to compare leadership skills of graduating EM residents from 3- to 4-year programs during simulated pediatric resuscitations using a previously validated leadership assessment tool, the Concise Assessment of Leader Management (CALM). METHODS: This was a prospective, multicenter, simulation-based cohort pilot study that included graduating 3rd- and 4th-year EM resident physicians from 6 EM residency programs. We measured leadership performance across 3 simulated pediatric resuscitations (sepsis, seizure, cardiac arrest) using the CALM tool and compared leadership scores between the 3rd- and 4th-year resident cohorts. We also correlated leadership to self-efficacy scores. RESULTS: Data was analyzed for 47 participating residents (24 3rd-year residents and 23 4th-year residents). Out of a total possible CALM score of 66, residents from 3-year programs scored 45.2 [SD ± 5.2], 46.8 [SD ± 5.0], and 46.6 [SD ± 4.7], whereas residents from 4-year programs scored 45.5 [SD ± 5.2], 46.4 [SD ± 5.0], and 48.2 [SD ± 4.3] during the sepsis, seizure, and cardiac arrest cases, respectively. The mean leadership score across all 3 cases for the 3-year cohort was 46.2 [SD ± 4.8] versus 46.7 [SD ± 4.5] (P = 0.715) for the 4-year cohort. CONCLUSIONS: These data show feasibility for a larger cohort project and, while not statistically significant, suggest no difference in leadership skills between 3rd- and 4th-year EM residents in our study cohort. This pilot study provides the basis of future work that will assess a larger multicenter cohort with the hope to obtain a more generalizable dataset.

Multiple Organ Dysfunction and Critically Ill Children With Acute Myeloid Leukemia: Single-Center Retrospective Cohort Study.

OBJECTIVES: To describe the prevalence of multiple organ dysfunction syndrome (MODS) and critical care utilization in children and young adults with acute myeloid leukemia (AML) who have not undergone hematopoietic cell transplantation (HCT). DESIGN: Retrospective cohort study of MODS (defined as dysfunction of two or more organ systems) occurring any day within the first 72 hours of PICU admission. SETTING: Large, quaternary-care children's hospital. PATIENTS: Patients 1 month through 26 years old who were treated for AML from 2011-2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty patients with AML were included. These 80 patients had a total of 409 total non-HCT-related hospital and 71 PICU admissions. The majority 53 of 71 of PICU admissions (75%) were associated with MODS within the first 72 hours. MODS was present in 49 of 71 of PICU admissions (69%) on day 1, 29 of 52 (56%) on day 2, and 25 of 32 (78%) on day 3. The organ systems most often involved were hematologic, respiratory, and cardiovascular. There was an increasing proportion of renal failure (8/71 [11%] on day 1 to 8/32 [25%] on day 3; p = 0.02) and respiratory failure (33/71 [47%] to 24/32 [75%]; p = 0.001) as PICU stay progressed. The presence of MODS on day 1 was associated with a longer PICU length of stay (LOS) (ß = 5.4 [95% CI, 0.7-10.2]; p = 0.024) and over a six-fold increased risk of an LOS over 2 days (odds ratio, 6.08 [95% CI, 1.59-23.23]; p = 0.008). Respiratory failure on admission was associated with higher risk of increased LOS. CONCLUSIONS: AML patients frequently require intensive care. In this cohort, MODS occurred in over half of PICU admissions and was associated with longer PICU LOS. Respiratory failure was associated with the development of MODS and progressive MODS, as well as prolonged LOS.

Diabetic Ketoacidosis With Refractory Hypokalemia Leading to Cardiac Arrest.

Diabetic ketoacidosis (DKA) is known to cause total body potassium depletion, but during initial presentation, very few patients are hypokalemic, and even fewer patients experience clinical effects. As the correction of acidosis and insulin drive potassium intracellularly, measured serum potassium levels decrease and require repletion. This phenomenon is well described, and severe hypokalemia necessitates delaying insulin therapy. Less well described is the kaliuretic nature of treatments of cerebral edema. We present a case of an adolescent male with new-onset type 2 diabetes who presented in DKA with signs of cerebral edema, hyperosmolarity, and hypokalemia. As insulin and cerebral edema therapy were initiated, his hypokalemia worsened despite significant IV repletion, eventually leading to ventricular tachycardia and cardiac arrest. Over the following 36 hours, the patient received >590 milliequivalents (mEq) of potassium. He was discharged home 12 days after admission without sequelae of his cardiac arrest.

Rapid Cycle Deliberate Practice Versus Traditional Simulation for Training Extracorporeal Membrane Oxygenation Specialists in Circuit Air Emergency Management: A Randomized Trial.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a highly complex therapy used to support critically ill patients. Simulation-based training of ECMO specialists in the management of ECMO emergencies has been described in the literature, but optimal methods are not currently established. The objective of this study was to compare rapid cycle deliberate practice (RCDP) simulation versus traditional simulation (TS) with reflective debriefing for training ECMO specialists in the management of arterial air emergencies. METHODS: A prospective, randomized, pre-post interventional design was used to compare the impact of RCDP training with that of TS training on ECMO specialist performance during a simulated ECMO circuit emergency. Participants were divided into 2 training groups-RCDP and TS. Each participant completed a simulated arterial air emergency scenario before training, immediately after training, and again 3 months later. The primary outcome was the time required by individual participants to complete critical clinical actions. RESULTS: Twenty-four ECMO specialists completed the study. Immediately after the training, the RCDP group had faster times to dissociate the patient from the ECMO circuit (11-seconds RCDP vs. 16-seconds TS, P = 0.03) and times to re-establish ECMO support (59-seconds RCDP vs. 82.5-seconds TS, P = 0.01). Follow-up testing at 3 months showed persistence in faster times to re-establish ECMO support in the RCDP group (114-seconds RCDP vs. 199-seconds TS, P = 0.01). CONCLUSIONS: Rapid cycle deliberate practice simulation provides a superior curriculum and method of training ECMO specialists in the management of arterial air emergencies in comparison with traditional simulation.

Using a Semi-Structured Qualitative Interview to Evaluate Pediatric Interns' Use of the Electronic Medical Record in a Simulated Setting.

Introduction Effective use of electronic medical record (EMR) is paramount to delivering safe and effective care. Current EMR education is inadequate, with literature showing frequent deficiencies in skills needed to obtain and interpret data. This study aims to evaluate pediatric interns' perception of EMR inclusion in scenario-based simulation training. Methods A total of 13 pediatric interns participated in an EMR-enhanced, multidisciplinary simulation of a pediatric patient with septic shock during the 2019-2020 academic year. Following the simulation, the interns participated in a semi-structured interview to evaluate the experience of having the EMR incorporated into the simulation and what benefits it offers. Results Of the 13 interns, 12 (92%) felt that incorporating the EMR into the simulation increased the realism of the scenario. All (100%) interns reported that EMR inclusion led to increased learning about the EMR, including gaining or re-learning skills needed to access or interpret electronic clinical data. Participants felt that EMR inclusion in the simulation provided valuable learning opportunities not present in traditional EMR education. Conclusions Integrating the EMR into simulation is viewed positively by pediatric interns, is perceived to improve simulation realism, and helps teach important EMR skills. EMR training would benefit from incorporation into scenario-based simulations.

Rapid cycle deliberate practice improves and sustains paediatric resident PALS performance.

Objectives: Paediatric cardiopulmonary arrest resuscitation is a critically important skill but infrequently used in clinical practice. Therefore, resuscitation knowledge relies heavily on formal training which is vulnerable to rapid knowledge decay. We evaluate knowledge and skill retention post-training using rapid cycle deliberate practice (RCDP). Design: Pilot, non-blinded, single-arm study. Setting: Pediatric Simulation Center at Children's of Alabama. Participants: 42 paediatric residents at a large, tertiary care, academic children's hospital were enrolled in this simulation-based resuscitation study. Interventions: Each participant led a 7 min preintervention arrest scenario as a baseline test. After testing, participants were trained individually in the paediatric advanced life support (PALS) skills necessary for resuscitation of a patient in pulseless electrical activity and ventricular fibrillation using RCDP-a simulation method using frequent expert feedback and repeated opportunities for the learner to incorporate new learning. Immediately post-training, participants were retested as leaders of a different paediatric arrest scenario. 3 months post-training participants returned to complete a final simulation scenario. Main outcome measures: To evaluate knowledge and skill retention following PALS training. Results: Preintervention data demonstrated poor baseline resident performance with an average PALS score of 52%. Performance improved to 94% immediately post-training and this improvement largely persisted at 3 months, with an average performance of 81%. In addition to improvements in performance, individual skills improved including communication, recognition of rhythms, early chest compressions and rapid administration of epinephrine or defibrillation. Conclusions: RCDP training was associated with significant improvements in resident performance during simulated paediatric resuscitation and high retention of those improvements.

Gamification in Action: Theoretical and Practical Considerations for Medical Educators.

Gamification involves the application of game design elements to traditionally nongame contexts. It is increasingly being used as an adjunct to traditional teaching strategies in medical education to engage the millennial learner and enhance adult learning. The extant literature has focused on determining whether the implementation of gamification results in better learning outcomes, leading to a dearth of research examining its theoretical underpinnings within the medical education context. The authors define gamification, explore how gamification works within the medical education context using self-determination theory as an explanatory mechanism for enhanced engagement and motivation, and discuss common roadblocks and challenges to implementing gamification.Although previous gamification research has largely focused on determining whether implementation of gamification in medical education leads to better learning outcomes, the authors recommend that future research should explore how and under what conditions gamification is likely to be effective. Selective, purposeful gamification that aligns with learning goals has the potential to increase learner motivation and engagement and, ultimately, learning. In line with self-determination theory, game design elements can be used to enhance learners' feelings of relatedness, autonomy, and competence to foster learners' intrinsic motivation. Poorly applied game design elements, however, may undermine these basic psychological needs by the overjustification effect or through negative effects of competition. Educators must, therefore, clearly understand the benefits and pitfalls of gamification in curricular design, take a thoughtful approach when integrating game design elements, and consider the types of learners and overarching learning objectives.