Emergency Medicine Experts Research Articles

Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T-Cell Therapy: ASCO Guideline.

To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with chimeric antigen receptor (CAR) T-cell therapy. A multidisciplinary panel of medical oncology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to develop the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 to 2021. The systematic review identified 35 eligible publications. Because of the paucity of high-quality evidence, recommendations are based on expert consensus. The multidisciplinary team issued recommendations to aid in the recognition, workup, evaluation, and management of the most common CAR T-cell-related toxicities, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, B-cell aplasia, cytopenias, and infections. Management of short-term toxicities associated with CAR T cells begins with supportive care for most patients, but may require pharmacologic interventions for those without adequate response. Management of patients with prolonged or severe CAR T-cell-associated cytokine release syndrome includes treatment with tocilizumab with or without a corticosteroid. On the basis of the potential for rapid decline, patients with moderate to severe immune effector cell-associated neurotoxicity syndrome should be managed with corticosteroids and supportive care.Additional information is available at www.asco.org/supportive-care-guidelines.

The Saudi Critical Care Society practice guidelines on the management of COVID-19 in the ICU: Therapy section

BackgroundThe rapid increase in coronavirus disease 2019 (COVID-19) cases during the subsequent waves in Saudi Arabia and other countries prompted the Saudi Critical Care Society (SCCS) to put together a panel of experts to issue evidence-based recommendations for the management of COVID-19 in the intensive care unit (ICU). MethodsThe SCCS COVID-19 panel included 51 experts with expertise in critical care, respirology, infectious disease, epidemiology, emergency medicine, clinical pharmacy, nursing, respiratory therapy, methodology, and health policy. All members completed an electronic conflict of interest disclosure form. The panel addressed 9 questions that are related to the therapy of COVID-19 in the ICU. We identified relevant systematic reviews and clinical trials, then used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach as well as the evidence-to-decision framework (EtD) to assess the quality of evidence and generate recommendations. ResultsThe SCCS COVID-19 panel issued 12 recommendations on pharmacotherapeutic interventions (immunomodulators, antiviral agents, and anticoagulants) for severe and critical COVID-19, of which 3 were strong recommendations and 9 were weak recommendations. ConclusionThe SCCS COVID-19 panel used the GRADE approach to formulate recommendations on therapy for COVID-19 in the ICU. The EtD framework allows adaptation of these recommendations in different contexts. The SCCS guideline committee will update recommendations as new evidence becomes available.

A Narrative Review of Trauma Care Delivery in India: Challenges and Opportunities

It is estimated that the cost of road accidents in India is around 3% of the Gross Domestic Product of the country. On average, 400 persons die daily in road accidents in India, and cities, such as New Delhi and the national capital region are on the top of the list of road accident causalities. Based on the Basilica agreement, the Indian government has initiated various policy changes and infrastructure development along the national highways which include the redesign of blindspots on the roads and the infliction of heavy penalties for the violation of traffic rules and compliances. On the academic front, the Indo-US Emergency Medicine forum has inaugurated an academic college for emergency medicine in India that cooperates with various government and private healthcare providers and policymakers for the improvement of emergency/trauma care delivery. Lately, few business schools and healthcare educational institutes have focused on interdisciplinary training and research centers in the area of emergency care delivery. Policymakers are also proactively working with various organizations to implement new rules and compliance mechanisms. This prospective study entails a detailed review of the literature using keywords in the PubMed journals, news articles, and media reports. Authors encountered studies in the area of trauma care delivery in India and other countries in their comprehensive field research. Almost 100% of the cases were medico-legal and only one case out of 100 was an insured patient. Furthermore, 87% of the cases were new and only 13% were review cases. Based on the conducted analysis, the number of accidents reduced across the country after the implementation of the New Motor Vehicle Act in the year 2019. It is worth mentioning that, the government launched awareness programs for the public as well. Some of the major challenges identified included lack of coordination and institutional mechanisms for an integrated emergency care delivery, poor referral processes, inadequate ambulance services, lack of third-party coordination, and poor in-hospital resources, particularly in public healthcare organizations. Apart from these, there was an acute shortage of trained emergency medicine experts at all levels. Trauma care delivery is a complex issue and its accomplishment requires good coordination and collaboration among stakeholders. The study identified various challenges and opportunities for the improvement of trauma care delivery in India. There is an immense need and opportunity for the modification of the emergency care delivery system through the introduction of appropriate changes in the transportation policy, emergency care delivery models, institutional mechanisms, such as referral process, and appropriate resource allocation at different levels of care delivery system.

Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities.

The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for “home hospital” services. A “home hospital” is the home‐based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital‐level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine.

Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM. Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important." Round1 of voting included 94 research questions, expanded to 103 questions in round2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety). The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.

Modified Manikin for Tracheoinnominate Artery Fistula.

This simulator is designed to instruct emergency medicine residents in tracheostomy training that involves bleeding from the tracheostomy site. Any resident, fellow, or attending physician who cares for patients with complications from their tracheostomy might benefit from this innovation. The emergency medicine provider must maintain proficiency in caring for patients with complications from their tracheostomy. In the United States, over 110,000 patients receive tracheostomies per year.1 A rare but catastrophic complication of tracheostomies, usually within the first month of placement, is a tracheoinnominate artery fistula (TIAF). This complication occurs in 0.7% of tracheostomy patients and carries a 50-70% mortality.1,2 We modified a low-fidelity tracheostomy manikin to instruct learners in the stepwise management of hemorrhage from a TIAF. By the end of this educational session, learners will be able to:Perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site.Describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF.Demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver.Verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above.Demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol. This modified manikin is a useful training tool for any healthcare provider who is involved in the treatment and stabilization of a variety of tracheostomy emergencies, from bleeding to infection to obstruction or dislodgement. Our case was presented on two separate occasions, to otolaryngology interns (PGY-1), and emergency medicine residents (PGY 1-3). It involved the care of a patient with a sentinel bleed and subsequent hemorrhage from a tracheoinnominate artery fistula (TIAF). This low-fidelity tracheostomy manikin provides the ideal platform for any complex, tracheostomy case, particularly where ongoing bleeding from the tracheostomy site might permanently damage the electrical circuitry of a high-fidelity model. We initially fashioned this modified manikin for tracheostomy training during a simulation "boot camp" for otolaryngology PGY-1 residents. Our use of this modified manikin for tracheostomy training was a useful teaching tool during our otolaryngology intern "boot camp." As a result, we organized a subsequent simulation training session with our PGY 1-3 emergency medicine residents to provide similar instruction in management of a TIAF. We provided a pre- and a post-simulation survey for the 33 emergency medicine residents who participated in the TIAF simulation with our modified tracheostomy manikin. There were 11 residents from each of the PGY-1, PGY-2, and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-simulation survey, and 33 residents (100%) completed the post-simulation survey. We used a 6-point Likert Scale from "strongly agree" to "strongly disagree" to assess a resident's knowledge of multiple learning objectives within this simulation. The pre- and post-simulation survey supported this simulation and manikin innovation as a useful teaching tool for tracheostomy emergencies such as a TIAF. This was a useful innovation for emergency provider training in the recognition and management of a TIAF, a rare but emergent tracheostomy complication. In addition to this bleeding complication, this innovation might be useful for a variety of tracheostomy emergencies such as site infection, obstruction, and tube dislodgement. We highly recommend the involvement of both an emergency medicine and otolaryngology content expert in the design and debriefing of tracheostomy cases with this modified manikin. In our experience, a facilitated debriefing by an experienced clinician and educator from both fields provided a diverse perspective for challenging cases such as bleeding from a TIAF. Difficult airway, tracheostomy, tracheoinnominate fistula, hemorrhagic shock, tracheostomy complications, Utley Maneuver.

After the Match

After the Match

Les publications des experts médicaux : l’exemple de l’anesthésie-réanimation

Forensic expertise becomes dominant in our society. Several reports questioned the competence of medical experts. We analysed the scientific competence of the 136 experts in Anaesthesia, Intensive Care and Emergency Medicine from senior courts in France. For that purpose, we made the choice of the H-Index and the number of scientific publications as markers of quality, using Google Scholar and PubMed databases. Thirty-five percent of experts have an H-Index equal to zero and 27 % never published. Out of the 104 experts who published at least one scientific article, 27 (26 %) did not publish for at least 10 years. The present study illustrates the great heterogeneity of the medical expert population regarding our criterions of judgement. This questions the selection and the operating mode of legal experts. There is a major difference with the selection process performed by the French Conciliation and Compensation Commissions. We propose that the official scholarly societies should be consulted during the appointment process.

Facing Disaster During a COVID-19 Outbreak: What Emergency Medicine Experts Should Know?

Context: Since December 2019, the new coronavirus (COVID-19) has been identified as one of the significant challenges in the health systems of countries. Recently, the development and equipping of hospitals and medical centers have been considered as a priority, providing a variety of advanced services in the areas of diagnostic, therapeutic, and supportive services to patients. The present review aimed to shed light on the importance and crucial role of knowledge in the field of emergency medicine during the COVID-19 pandemic and to compare the local and international guidelines. Finally, in addition to the workplace and emergency practitioners’ acts, alongside the especial need to frequently disinfect with appropriate antiseptic materials, negative pressure ventilation should also be in the triage and emergency rooms. Besides, personal protection requirements should be sufficiently accessible, and emergency physicians should be trained to use them properly while adhering to safety principles. It is also recommended to use a cap, gown, appropriate mask, shield, and gloves during treatment, diagnostic and supportive measures, and practice frequent hand washing with antiseptic materials like alcohol solutions, as it reduces the risk of infection transmission. Moreover, it is imperative that nurses and physicians working in emergencies follow all safety principles at the end of the shift before entering their homes. Conclusions: Ultimately, the final goal is to reduce the virus transmission through early detection, supportive, diagnostic, and therapeutic actions, and appropriate follow-up.

Impact of Face-to-Face Teaching in Addition to Electronic Learning on Personal Protective Equipment Doffing Proficiency in Student Paramedics: Protocol for a Randomized Controlled Trial.

BackgroundThe COVID-19 pandemic has brought attention to the importance of correctly using personal protective equipment (PPE). Doffing is a critical phase that increases the risk of contamination of health care workers. Although a gamified electronic learning (e-learning) module has been shown to increase the adequate choice of PPE among prehospital personnel, it failed to enhance knowledge regarding donning and doffing sequences. Adding other training modalities such as face-to-face training to these e-learning tools is therefore necessary to increase prehospital staff proficiency and thus help reduce the risk of contamination.ObjectiveThe aim of this study is to assess the impact of the Peyton 4-step approach in addition to a gamified e-learning module for teaching the PPE doffing sequence to first-year paramedic students.MethodsParticipants will first follow a gamified e-learning module before being randomized into one of two groups. In the control group, participants will be asked to perform a PPE doffing sequence, which will be video-recorded to allow for subsequent assessment. In the experimental group, participants will first undergo face-to-face training performed by third-year students using the Peyton 4-step approach before performing the doffing sequence themselves, which will also be video-recorded. All participants will then be asked to reconstruct the doffing sequence on an online platform. The recorded sequences will be assessed independently by two investigators: a prehospital emergency medicine expert and an infection prevention and control specialist. The assessors will be blinded to group allocation. Four to eight weeks after this first intervention, all participants will be asked to record the doffing sequence once again for a subsequent skill retention assessment and to reconstruct the sequence on the same online platform to assess knowledge retention. Finally, participants belonging to the control group will follow face-to-face training.ResultsThe study protocol has been presented to the regional ethics committee (Req-2020-01340), which issued a declaration of no objection as such projects do not fall within the scope of the Swiss federal law on human research. Study sessions were performed in January and February 2021 in Geneva, and will be performed in April and June 2021 in Bern.ConclusionsThis study should help to determine whether face-to-face training using the Peyton 4-step approach improves the application and knowledge retention of a complex procedure when combined with an e-learning module.International Registered Report Identifier (IRRID)PRR1-10.2196/26927

Identifying the Gaps: Needs Assessment to Guide Development of a Dedicated Toxicology Curriculum for Emergency Medicine Residents

The American Board of Emergency Medicine identifies medical toxicology as an essential curricular element for emergency medicine (EM) residencies; however, access to medicaltoxicology education varies widely by institution. We hypothesized thatEM residents areuncomfortable with core toxicology content and would be interested in a dedicated toxicology curriculum. An electronic needs assessmentsurvey developed by experts in EM and medical toxicology was sent to residents and program leadership at nine EM programs participating in the Emergency Medicine Education Research Alliance (EMERA), a geographically diverse sampling ofacademic EM residency programs. We queried the presence of a current toxicology curriculum, interest in a dedicated toxicology curriculum, and comfort with core toxicology concepts for board examinations and in clinical practice. RESULTS: A total of 148 residents and 8facultyleadership completed the survey. Only 29% ofresidentrespondents felt comfortable with toxicology concepts, and only 66% of respondents reported access to a toxicology curriculum. Of those without a known toxicology curriculum, mostwere interested in a formal curriculum. Faculty respondents reported 6/8 programs offered a toxicology curriculum. Faculty at the two programs without a formal curriculum expressed interest in a dedicated curriculum. Emergency medicineresidents remain uncomfortable with the core toxicology content in clinical practice. The majority of residents without a known toxicology curriculum would be interested in a dedicated toxicology curriculum.

Point-of-care ultrasonography for the diagnosis of testicular torsion: a practical resident curriculum.

BackgroundPrompt Doppler ultrasonography to aid in diagnosis is often key to managing testicular torsion, but there may be delays in access; a faster, more widely available alternative is point-of-care ultrasonography (POCUS). The purpose of this study was to develop and evaluate a scrotal POCUS curriculum for urology and emergency medicine residents.MethodsContent experts in urology, emergency medicine and diagnostic imaging collaborated in a modified Delphi method to design a practical didactic curriculum for scrotal POCUS for the identification of testicular torsion. Training included 3 online video teaching modules and a 1-hour hands-on teaching session with standardized adult patients. We evaluated participants’ competency in scrotal POCUS using a validated scale. We assessed participants’ knowledge, comfort and confidence in performing scrotal POCUS before and after the intervention and at 3 months.ResultsTwenty-four urology (n = 12) and emergency medicine (n = 12) residents participated in the curriculum. After hands-on practice, 23 participants (96%) were deemed competent at scrotal POCUS. Pre–post testing showed significant improvement in knowledge (mean score 63% v. 80%, p < 0.001), comfort (mean Likert score 0.6 v. 3.6, p < 0.001) and confidence (mean Likert score 1.0 v. 2.1, p < 0.001) after the intervention. These effects were maintained at the 3-month assessment.ConclusionThe scrotal POCUS curriculum was effective and acceptable to both urology and emergency medicine residents. The findings suggest that scrotal POCUS can be learned effectively through a short hands-on session and didactic instruction.

Health Workforce Development in Health Emergency and Disaster Risk Management: The Need for Evidence-Based Recommendations.

The Sendai Framework for Disaster Risk Reduction 2015–2030 placed human health at the centre of disaster risk reduction, calling for the global community to enhance local and national health emergency and disaster risk management (Health EDRM). The Health EDRM Framework, published in 2019, describes the functions required for comprehensive disaster risk management across prevention, preparedness, readiness, response, and recovery to improve the resilience and health security of communities, countries, and health systems. Evidence-based Health EDRM workforce development is vital. However, there are still significant gaps in the evidence identifying common competencies for training and education programmes, and the clarification of strategies for workforce retention, motivation, deployment, and coordination. Initiated in June 2020, this project includes literature reviews, case studies, and an expert consensus (modified Delphi) study. Literature reviews in English, Japanese, and Chinese aim to identify research gaps and explore core competencies for Health EDRM workforce training. Thirteen Health EDRM related case studies from six WHO regions will illustrate best practices (and pitfalls) and inform the consensus study. Consensus will be sought from global experts in emergency and disaster medicine, nursing, public health and related disciplines. Recommendations for developing effective health workforce strategies for low- and middle-income countries and high-income countries will then be disseminated.

The Implementation of a Collaborative Pediatric Telesimulation Intervention in Rural Critical Access Hospitals.

Over 5.8 million pediatric visits to rural emergency department (EDs) occur each year in the United States. Most rural EDs care for less than five pediatric patients per day and are not well prepared for pediatrics. Simulation has been associated with improvements in pediatric preparedness. The implementation of pediatric simulation in rural settings is challenging due to limited access to equipment and pediatric specialists. Telesimulation involves a remote facilitator interacting with onsite learners. This article aims to describe the implementation experiences and participant feedback of a 1-year remotely facilitated pediatric emergency telesimulation program in three critical-access hospitals. Three hospitals were recruited to participate with a nurse manager serving as the on-site lead. The managers worked with a study investigator to set up the simulation technology during an in-person pilot testing visit with the off-site facilitators. A curriculum consisting of eight pediatric telesimulations and debriefings was conducted over a 12-month period. Participant feedback was collected via a paper survey after each simulation. Implementation metrics were collected after each session including technical and logistic issues. Of 147 participant feedback surveys 90% reported that pediatric simulations should be conducted on a regular basis and overall feedback was positive. Forty-seven of 48 simulations were completed on the first attempt with few major technologic issues. The most common issue encountered related to the simulator not working correctly locally and involved the facilitator running the session without the heart and lung sounds. All debriefings occurred without any issues. This replicable telesimulation program can be used in the small, rural hospital setting, overcoming time and distance barriers and lending pediatric emergency medicine expertise to the education of critical-access hospital providers.

A National US Survey of Pediatric Emergency Department Coronavirus Pandemic Preparedness.

ObjectiveWe aim to describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a diverse set of pediatric emergency departments (PEDs) within the United States.MethodsWe conducted a prospective multicenter survey of PED medical director(s) from selected children’s hospitals recruited through a long established national research network. The questionnaire was developed by physicians with expertise in pediatric emergency medicine, disaster readiness, human factors, and survey development. Thirty-five children’s hospitals were identified for recruitment through an established national research network.ResultsWe report on survey responses from 25 (71%) of 35 PEDs, of which 64% were located within academic children's hospitals. All PEDs witnessed decreases in non–COVID-19 patients, 60% had COVID-19–dedicated units, and 32% changed their unit pediatric patient age to include adult patients. All PEDs implemented changes to their staffing model, with the most common change impacting their physician staffing (80%) and triaging model (76%). All PEDs conducted training for appropriate donning and doffing of personal protective equipment (PPE), and 62% reported shortages in PPE. The majority implemented changes in the airway management protocols (84%) and cardiac arrest management in COVID patients (76%). The most common training modalities were video/teleconference (84%) and simulation-based training (72%). The most common learning objectives were team dynamics (60%), and PPE and individual procedural skills (56%).ConclusionsThis national survey provides insight into PED preparedness efforts, training innovations, and practice changes implemented during the start of COVID-19 pandemic. Pediatric emergency departments implemented broad strategies including modifications to staffing, workflow, and clinical practice while using video/teleconference and simulation as preferred training modalities. Further research is needed to advance the level of preparedness and support deep learning about which preparedness actions were effective for future pandemics.

Diagnosing Dyspneic Older Adult Emergency Department Patients: A Pilot Study.

Dyspnea is the second leading cause of US emergency department (ED) visits and an independent predictor of morbidity and mortality1 in older adult patients aged ≥65 years. Unfortunately, the diagnosis of the cause of dyspnea presents diagnostic challenges to emergency physicians2-4 that disproportionately affects older adults.5 One in 5 dyspneic older adults experience missed diagnosis in the ED2 and 21% are treated for ≥1 pneumonia, acute exacerbation of chronic obstructive pulmonary disease [COPD], and acute exacerbation of heart failure [HF].5 Importantly, some may have multiple causes of their dyspnea but accurate diagnosis remains critical.

A call for collaboration and consensus on training for endotracheal intubation in the medical intensive care unit

Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One study suggests that 40% of the US PCCM trainees feel they would not be proficient in EI upon graduation. This article presents a review of the EI training literature; the recommendations of a national group of PCCM, anesthesiology, emergency medicine, and pediatric experts; and a call for further research, collaboration, and consensus guidelines.

Adapting two American Decision Aids for Mild Traumatic Brain Injury to the Canadian Context Using the Nominal Group Technique.

Decision aids are patient-focused tools that have the potential to reduce the overuse of head computed tomography (CT) scans. The objective of this study was to create a consensus among Canadian mild traumatic brain injury and emergency medicine experts on modifications required to adapt two American decision aids about head CT use for adult and paediatric mild traumatic brain injury to the Canadian context. We invited 21 Canadian stakeholders and the two authors of the American decision aids to a Nominal Group Technique consensus meeting to generate suggestions for adapting the decision aids. This method encourages idea generation and sharing between team members. Each idea was discussed and then prioritised using a voting system. We collected data using videotaping, writing material and online collaborative writing tools. The modifications proposed were analysed using a qualitative thematic content analysis. Twenty-one participants took part in the meeting, including researchers and clinician researchers (n = 9; 43%), patient partners (n = 3; 14%) and decision makers (n = 2; 10%). A total of 84 ideas were generated. Participants highlighted the need to clarify the purpose of the decision aids, the nature of the problem being addressed and the target population. The tools require sociocultural adaptations, better identification of their target population, better description of head CT utility, advantages and related risks, modification of the visual and written representation of the risk of brain injury and head CT use, and locally adapted, patient follow-up plans. This study based on a Nominal Group Technique identified several adaptations for two American decision aids about head CT use for mild traumatic brain injury to support their use in Canada's different healthcare, social, cultural and legal context. These adaptations concerned the target users of the decision aids, the information presented, and how the benefits and risks were communicated in the decision aids. Future steps include prototyping the two adapted decision aids, conducting formative evaluations with actual emergency department patients and clinicians, and measuring the impact of the adapted tools on CT scan use.

Using a Simulated Model and Mastery Learning Approach to Teach the Ultrasound-guided Serratus Anterior Plane Block to Emergency Medicine Residents: A Pilot Study.

The serratus anterior plane block (SAPB) is a safe, single-injection alternative for pain control in patients with rib fractures. This pilot study aims to teach the ultrasound-guided SAPB to emergency medicine (EM) residents using a mastery learning approach. A 19-item checklist was created and mastery was determined to be 17 of 19 items correct. This pass score was established using a Mastery Angoff standard-setting exercise with a group of EM experts. Learners participated in baseline testing on a simulated model and performance was assessed by two raters. Learners then watched an instructional video and participated in an individualized teaching session. Learners underwent deliberate practice followed by posttesting until mastery was achieved. Score differences in baseline testing and posttesting were analyzed using a paired t-test. Pre- and posttesting surveys were also completed by participants. Twenty-eight PGY-1 to -4 residents volunteered to participate in the study. The range of reported SAPBs seen previously was 0 to 5. The mean (±SD) number of items correct on the checklist for initial testing was 8.5 of 19 (±2.7), while the mean (±SD) final score was 18 of 19 (±0.6; p<0.001). All participants met mastery standards after the curriculum intervention. Median self-reported procedural confidence was 2 out of 5 on a 5-point Likert scale before the session and 5 out of 5 after the session (Z=-4.681, p<0.001). Using a mastery learning approach and simulated model, we were able to successfully train EM residents to perform the SAPB at a level of mastery and increase their overall confidence in executing this procedure.

Highly Infectious Diseases in Critical Care: A Comprehensive Clinical Guide

In the seventh century, the prophet of Islam, Muhammad, said “If you hear of plague (outbreak) in a land, do not enter it; and if the plague (outbreak) occurs in a land while you are in it, do not leave it,” and in 2015, Bill Gates said “If anything kills over 10 million people in the next few decades, it’s most likely to be a highly infectious virus. We’re not ready for the next epidemic.” Throughout history, the world has been hit by numerous epidemics that caused lots of losses and sufferings. Today, in the time of the coronavirus disease 2019 (COVID-19) pandemic, it became crucial for all health care practitioners to expand their knowledge of infectious diseases. Jorge Hidalgo, a Critical Care specialist from Belize, and Laila Woc-Colburn, a Tropical Medicine specialist from the United States, have edited a new book, Highly Infectious Diseases in Critical Care: A Comprehensive Clinical Guide, intended primarily, but not exclusively, for critical care providers. Each of the editors has a significant research expertise in the field of infectious diseases. A group of international experts in infectious diseases, internal medicine, critical care, emergency medicine, anesthesiology, and microbiology have contributed to writing its various chapters. The book discusses the epidemiological and microbiological aspects of the commonly encountered infectious diseases, discusses the diagnostic and therapeutic strategies focusing on critical care management, and describes the steps for an intensive care unit (ICU) to prepare for infectious diseases and epidemics. It is unique in being written from critical care perspective and is available in printed (hardcover) and electronic (PDF) versions. The book comprises 16 properly ordered chapters. The first 3 chapters provide general information about the history, epidemiology, and microbiology of infectious diseases and emphasize the role of various community facilities and health care systems involved in the management of outbreaks. The fourth chapter discusses the laboratory methods of diagnosing viral, bacterial, fungal, and parasitic infections. The following chapters comprehensively discuss the epidemiology, microbiology, diagnosis, and management of the most prevalent and hazardous infectious diseases, including respiratory viral infections (influenza, measles, coronavirus, and smallpox), zoonotic infections (anthrax, plague, and tularemia), viral hemorrhagic fevers (Ebola virus, Marburg virus, Crimean-Congo fever, Lassa fever, and yellow fever), multidrug-resistant bacteria (Enterococcus, Staphylococcus aureus, and Enterobacteriaceae), rabies, tetanus, malaria, and tuberculosis. In addition, 2 chapters discuss the pathogenesis and management of various central nervous system infections and the monitoring and management of intracranial pressure in patients with bacterial meningitis. The book concludes with 2 essential chapters describing how to plan and prepare an ICU for a highly infectious disease and how to declare and prepare for a pandemic. In general, the book provides a balanced combination between the basic epidemiological and microbiological knowledge and the clinical diagnostic and therapeutic applications. In addition, it provides valuable historical and cultural information and incorporates a number of important concepts, such as antibiotic resistance, biowarfare, and management in resource-limited settings. The sections of each chapter are neatly ordered and properly discussed, the presented figures and illustrations are informative, and the references are appropriate and adequate. The authors use an interesting, systematic style and a scientific, yet easy language. We have a number of comments. When discussing the history of previous epidemics, little information is provided about the important Spanish flu and cholera epidemics. An illustration summarizing the roles of different health care units in the triage of highly infectious diseases and in the setting of a suspected bioterrorism attack may be added to Chapter 3. In Chapter 4, the names of the authors are unnecessarily written after some subheadings. In Chapter 5, various viral infections (influenza, measles, coronavirus, and smallpox) are collectively discussed under each subheading (Biology, Epidemiology, Clinical Findings, Diagnosis, and Management). The different infections might have better been discussed separately in a systematic manner. Chapter 14 might have been entitled “Multidrug-Resistant Tuberculosis” rather than “Tuberculosis Multidrug Resistance.” Finally, in our opinion, Chapters 10 and 15 contain parts that are difficult to understand and need linguistic revision. In conclusion, Highly Infectious Diseases in Critical Care: A Comprehensive Clinical Guide is an excellent, concise resource that provides valuable information about the epidemiology, pathogenesis, and management of various infectious diseases and helps critical care practitioners to manage the current pandemic and to be “ready for the next epidemic.” Mohamed Mohamed Tawfik, MDAmal Ahmed Nour, MScDepartment of Anesthesia and Surgical Critical CareMansoura University HospitalsMansoura, Egypt[email protected]