Faculty Bibliography

BACKGROUND:Despite a high incidence of tracheostomy-related airway complications with potentially life-threatening implications, nonsurgical tracheostomy first-responders receive limited formal education on the management of tracheostomy emergencies. While the U.K. has developed multidisciplinary guidelines and education for tracheostomy emergencies, such programs have not been widely implemented in the United States. OBJECTIVE:We evaluated the feasibility and effectiveness of an immersive virtual reality (VR) simulation training as a potential generalizable and scalable approach to tracheostomy-related emergency training. METHODS:Over the academic year 2023-2024, critical care fellows were randomized to participate in tracheostomy emergency training either via immersive VR simulation or via small group discussion sessions facilitated by expert faculty. After each case-based educational intervention, participants were asked to manage four simulated tracheostomy-related emergencies involving common tracheostomy complications. Fellow performance was evaluated using a purpose-built task trainer. Three independent and blinded graders completed fellow scoring using a checklist assessment for which validation evidence was also collected. Fellows received pre- and post-intervention surveys to measure attitudes towards VR training. RESULTS:Nineteen out of 27 eligible fellows participated in the study, managing a total of 76 simulated tracheostomy emergencies. There were 10 fellows in the VR arm and 9 fellows in the Small Group arm. Out of a total possible 26 points on the checklist assessment, fellows in the VR group scored an average of 18.03 ± 3.39 compared to the Small Group score of 16.96 ± 4.41 (P = .558). Surveys indicated improvements in fellow confidence after the training and high levels of acceptance of the VR curriculum. CONCLUSIONS:An immersive VR educational intervention for the management of tracheostomy-related emergencies was feasible and well-received by learners. There was no significant difference in post-training checklist assessment scores between the VR and Small Group participants, suggesting non-inferiority of the VR intervention, and contributing validation evidence to our task trainer simulation assessment. FUNDING/BACKGROUND:This study was funded via the APCCMPD, CHEST, and ATS Education Research Award.

Despite a rapidly evolving role for advanced therapeutic interventions, the majority of patients with high-risk pulmonary embolism (PE) are still undertreated. Due to complex diagnosis and management, along with a high associated mortality rate, high-risk PE offers an excellent opportunity for simulation training. We present a simulated case of high-risk PE in a post-operative patient that is designed to teach key principles of diagnosis and management. The script is widely adaptable to many institutions and customisable to diverse learner populations.

Intro: The optimal strategy for weaning of respiratory support during lung recovery of patients requiring VV ECMO for acute respiratory failure is unknown. We hypothesized that earlier liberation from the ventilator in these patients may correlate with improved outcomes.
Method(s): We retrospectively reviewed all VV ECMO patients at our center from November 2015 to May 2019. Patients who were on VV ECMO as bridge to transplant or for isolated intraoperative indications were excluded. The final study population included 18 patients; 6 were liberated from mechanical ventilation prior to ECMO decannulation and 12 were decannulated from ECMO, but remained mechanically ventilated. Demographics and outcomes were compared between the two groups.
Result(s): Patients liberated from the ventilator prior to ECMO were treated for asthma, pneumonia and vasculitis (33% each) versus predominantly pneumonia (58%), had a lower rate of pre-existing lung disease (17% vs 33%), and lower APACHE II scores (median of 21 vs 24). These patients had longer duration of ECMO (220 vs 205 hours), less ventilator days (5 vs 20.5 days), higher average Richmond Agitation Scores (-1 vs -3), fewer days until they were able to get out of bed (4.5 vs 15 days), shorter ICU stays (16 vs 29 days), and were more likely to survive to hospital discharge (100% vs 67%).
Conclusion(s): Early ventilator liberation of patients on VV ECMO was associated with improved outcomes. Our study is limited by small sample size, retrospective design, and potential for confounding due to baseline differences between groups

INTRODUCTION/BACKGROUND:Rapid response teams (RRTs) have become ubiquitous among hospitals in North America, despite lack of robust evidence supporting their effectiveness. Many RRTs do not yet use cognitive aids during these high-stakes, low-frequency scenarios, and there are no standardized cognitive aids that are widely available for RRTs on medicine patients. We sought to design an emergency manual to improve resident performance in common RRT calls. METHODS:Residents from the New York University School of Medicine Internal Medicine Residency Program were asked to volunteer for the study. The intervention group was provided with a 2-minute scripted informational session on cognitive aids as well as access to a cognitive aid booklet, which they were allowed to use during the simulation. RESULTS:Resident performance was recorded and scored by a physician who was blinded to the purpose of the study using a predefined scoring card. Residents in the intervention group performed significantly better in the simulated RRT, by overall score (mean score = 7.33/10 and 6.26/10, respectively, P = 0.02), and by performance on the two critical interventions, giving the correct dose of naloxone (89% and 39%, respectively, P < 0.001) and checking the patient's blood glucose level (93% and 52%, respectively, P = 0.001). CONCLUSIONS:In a simulated scenario of opiate overdose, internal medicine residents who used a cognitive aid performed better on critical tasks than those residents who did not have a cognitive aid. The use of an appropriately designed cognitive aid with sufficient education could improve performance in critical scenarios.