Questions are based on overall goals of the EM residency. This is a prospective survey-based study using the standardized Likert agree-ment scale.
Two scales were used: a 6-item scale of agreement and a 6-item scale of frequency.
Survey questions were grouped into categories addressing proce-dure competency, critical care, throughput, communication, efficiency, multitasking, value to education, and administration.
Frequencies of the core procedures performed by residents at the FEDs were also calculated and correlated with whether there was an in-creased level of confidence. We examined procedures, which included adult and pediatric incision and drainage, fracture splinting, intubation, central line placement, slit lamp exam, conscious sedation, chest tube placement, and arthrocentesis. Subsequently, frequency questions asking how often a resident performs each of the core procedures were analyzed.
Percentages of residents who viewed the FED experience as valuable vs not were also calculated along with frequencies of core EM proce-dures performed by residents in the FEDs.χ2Goodness offit test was conducted for each question item. A level of significance (P value) for each question addressing the core competencies of residency training was calculated. It was then established whether there was significant level of agreement or disagreement with the FEDs impacting each core area of residency education.
A total of 21 residents met inclusion criteria postgraduate year 1 to 3. Of these residents, 95.2% felt that the experience helped them develop better communication strategies, teaching skills, and ability to simulta-neously manage multiple patients (P = .000). 90.5% agreed that the FED experience helped them balance quality care with optimal patient throughput and contributed overall to their education (Pb .001).
There was significant value to education with positive effect on strat-egies for life-long learning (P = .016), increased ability to treat all con-ditions presenting to the ED (P = .025), and positive contribution to education (Pb .001).
There was also significant positive level of agreement in indepen-dently directed patient evaluations and increased efficiency in task switching and managing a busy ED with limited resources (P = .001).
xWe found that a significant association exists between resident agreement that their FED experience increased their efficiency in task switching, managing the ED under high volume situations, and working one on one with the attending physician having a positive effect on their educational experience (2-sided P = .014), calculated with Fisher exact test.
The most commonly performed procedures at the FEDs were adult and pediatric laceration repair, incision and drainage (adult), and inde-pendent evaluation of radiographs. The frequency of procedural perfor-mance by residents at the FEDs correlates with perceived level of confidence in performing each procedure by residents. There was a sta-tistically significant level of agreement with 95.2% of residents feeling that the FED rotation increased their confidence with performing adult laceration repair (Pb .001). Residents also felt an increased level of confidence with pediatric laceration repair (P = .007) and incision and drainage (Pb .001).
We found that there was no statistically significant impact of FEDs on performance of critical care procedures and management of critical resuscitation (PN .275). We also found no significant agreement that the FED rotation helped residents better perform administrative tasks (P = .127).
The FED rotation provided a statistically significant impact on resi-dent education. It also provided essential core residency skills based on Accreditation Council for Graduate Medical Education program re-quirements in areas of ED throughput, communication skills, efficiency, procedures, and multitasking. There were a statistically significant num-ber of residents that viewed the rotation as valuable to their overall ed-ucation. These experiences may otherwise not be available in a large tertiary care center. Further studies are warranted.
Kseniya Orlik, MD⁎ Christina M. Campana, DO Department of Emergency Medicine, Akron General Medical Center, Akron, OH ⁎Corresponding author at: Department of Emergency Medicine, Akron General Medical Center, 1 Akron General Ave., Akron, OH 44307 Tel.: +1 330 962 9208; fax: +1 330 761 3416 E-mail addresses:KseniyaOrlik@gmail.com,scarletosugray9@yahoo.com
Michael S. Beeson, MD Erin L. Simon, DO Department of Emergency Medicine, Akron General Medical Center Akron, OH Northeast Ohio Medical University, Rootstown, OH E-mail addresses:Michael.Beeson@akrongeneral.org Esimon78@yahoo.com http://dx.doi.org/10.1016/j.ajem.2015.04.081
References
[1] ACGME. ACGME Program Requirements for Graduate Medical Education in Emergency Medicine; 2012 [Available athttps://www.acgme.org/acgmeweb/Portals/0/PFAssets/ 2013-PR-FAQ-PIF/110_emergency_medicine_07012013.pdf. Accessed July 12, 2014].
[2]Beeson M. Emergency Medicine Resident Progress and Promotion Department of
Emergency Medicine Akron General Medical Center; 2013 [Available].
A comparison of the ETView VivaSight SL against a fiberoptic bronchoscope for nasotracheal intubation of multitrauma patients during resuscitation. A randomized, crossover, manikin study☆,☆☆,★,★★
To the Editor,
The well-known blind nasotracheal intubation (NTI) is an advanced airway management technique, which involves“blindly” passing an endotracheal tube through the vocal cords. This technique is favored in difficult airway circumstances, especially when oral access is limited, or patient has a jaw injury[1]. Furthermore, to apply blind NTI, the patient should indicate spontaneous respiration. However, in the case of sudden cardiac arrest, when there is total cessation of respiration, the use of blind NTI can be problematic. Instead, there are alternative methods of intubation such as afiberoptic bronchoscope (the Olympus LF-V Intuba-tion Videoscope [FOB], Olympus MAF-GM IntubaIntuba-tion Videoscope; Olym-pus America, Center Valley, PA)[2]. However, due to the high price of FOBs, they are a rarity in emergency medical services practice. Therefore, in this study, the efficiency of an FOB was compared against the ETView VivaSight SL (ETView) ETView Ltd, Misgav, Israel)[3,4].
The aim of the study was to compare time and success rate of different available techniques for NTI in multitrauma patient during simulated resuscitation.
☆ Conflict of interest statement: The authors declare that they have no conflicts of interests.
☆☆ Author's contributions: LS, AK, ZT, and TE contributed significantly to the planning of the study and the study design. LS, AK, LC, ZT, and JM recruited the participants and col-lected data. LS and AK were principal investigators of this study and did major manuscript preparation. LS and LC prepared statistical analysis. LS, AK, LC, JM, TE, and ZT contributed significantly for manuscript editing and expertise.
★ Source of support: No sources of financial and material support to be declared. ★★ None of authors involved in this study has any financial relationship with any
man-ufacturers of intubation devices.
1097 Correspondence / American Journal of Emergency Medicine 33 (2015) 1093–1107
Figure. Flow chart of design and recruitment of participants according to Consolidated Standards Of Reporting Trials (CONSORT) statement.
Table 1
Data from scenario A: multitrauma patient without chest compression scenario. Data re-ported as median (IQR) or number (percentage)
Parameter assessed FOB ETView P
Time to intubation, median (IQR) 72.4 (41.4-89.5) 56.3 (40.1-81.5) b.001
Success rate 95.2% 100% NS Ease of intubation .037 1 5 (11.9%) 17 (40.5%) 2 21 (50.0%) 16 (38.1%) 3 13 (31.0%) 9 (21.4%) 4 3 (7.1%) 0 5 0 0
Abbreviation: NS, not statistically significant.
Table 2
Data from scenario B: multitrauma patient with uninterrupted chest compression scenario. Data reported as median (IQR) or number (percentage)
Parameter assessed FOB ETView P
Time to intubation, median (IQR) 84.3 (46.9-98.2) 59.6 (43.6-82.5) b.001
Success rate 90.1% 97.6% NS Ease of intubation .025 1 2 (4.8%) 11 (26.2%) 2 15 (35.7%) 18 (42.8%) 3 19 (45.2%) 13 (31.0%) 4 6 (14.3%) 0 5 0 0
The study has been approved by Institutional Review Board of the International Institute of Rescue Research and Education (approval 6.2015.02.26). The study was designed as an open, prospective, randomized, crossover trial. With voluntary written, informed consent, 42 anesthesia providers participated in this trial. The study ran from March 1, 2015 to April 4, 2015.
To simulate the scenario of a multitrauma patient, a standardized airway manikin with a regular airway (SIMman 3D; Laerdal, Stavanger, Norway) was placed on a Stryker trauma stretcher (Stryker, Kalamazoo, MI) in a neutral position. Elevation of the head and the upper body was not allowed. A correctlyfitting standard cervical immobilization collar (StifNeck Select; Laerdal) was applied to the manikin's neck to prevent 1098 Correspondence / American Journal of Emergency Medicine 33 (2015) 1093–1107
movement of the cervical spine. Subjects encountered 2 emergency scenarios:
1. Scenario A: a multitrauma patient scenario without chest compression. 2. Scenario B: a multitrauma patient scenario in which continuous chest compression was applied using a mechanical Lucas-2 (Physio-Control, Redmond, WA) chest compression (CC) system. Chest compression was provided according to American Heart Association resuscitation guidelines[5].
Nosotracheal intubation was performed using 2 devices: the FOB and ETView. Endotracheal intubations (ETIs) using the FOB were performed using a size 7.0 internal diameter tracheal tube (Portex; Smiths Medical, Keene, NH). Lubricant was preapplied to the tracheal tube, and a 10-mL syringe to block the tube's cuff as well as an AMBU resuscitator bag (AMBU, Copenhagen, Denmark) was readily available and within range of participants.
Before the study, all participants received a 10-minute standardized demonstration of the various intubation devices to make sure that they were familiar with their proper use. A Research Randomizer program was used [www.researchrandomizer.org] to order thefirst intubation method to be performed (Figure). After completing each ETI procedure, participants had a 10-minute break before performing intubation using the next method. Participants had only 1 ETI attempt with each intuba-tion method.
The primary outcome of the study was time to intubation, de-fined as the time from the participant picking up the FOB or ETView, until ventilation with the endotracheal tube was confirmed by the expansion of the manikin's lungs. The secondary outcome was the success of the intubation attempt, which was recorded when the success of the ventilation attempt was confirmed by the manikin's ventilation indicators.
The Statistica statistical package version 12.0 for Windows was used (StatSoft, Tulsa, OK). All results are shown as a number (percentage), median (±SD), or median and interquartile range (IQR). As data were found not to be normally distributed, nonparametric data were applied. Times needed to seasonal affective disorder exchange were compared using the Wilcoxon signed rank test. McNemar test was used to detect possible differences in exchange success rate for ETI. For comparison of Visual Analogue Scale (VAS), a 1-way analysis of variance with a post hoc (Schiffe) test was used. In all tests, Pb .05 was considered to in-dicate a significant effect.
In scenario A (multitrauma patient without chest compression), analysis showed that the average intubation time was shortest when using the ETView, 56.3 (40.1-81.5) seconds and longest when using the FOB, 72.4 (41.4-89.5) seconds. A statistically significant difference was noticed between the ETView and the FOB (Pb .001). The success rate using the FOB and the ETView varied and amounted to 95.2% vs 100%, respectively (Table 1).
In scenario B (multitrauma patient with uninterrupted chest compression), the results with the ETView were significantly bet-ter than with the FOB (Pb .05) for time to intubation and ease of intubation. Time to intubation is shown inTable 2. The success rate of ETI using the ETView was 97.6%, which was higher than with the FOB (90.1%); this difference was not statistically significant.
In this simulated trial, the ETView proves to be a promising vice for NTI during resuscitation by anesthesiologists. Use of this de-vice seems to offer advantages over the FOB during cardiopulmonary resuscitation. Further validation of the ETView in a clinical setting is required.
Zenon Truszewski, PhD, MD Department of Emergency Medicine, Medical University of Warsaw Warsaw, Poland
Lukasz Szarpak, PhD, MPH, EMT-P Department of Emergency Medicine, Medical University of Warsaw Warsaw, Poland Corresponding author at: Department of Emergency Medicine Medical University of Warsaw, Lindleya 4 St, 02-055 Warsaw, Poland Tel.: +48 500186225 E-mail address:Lukasz.szarpak@gmail.com
Lukasz Czyzewski, PhD, RN Department of Nephrologic Nursing, Medical University of Warsaw Warsaw, Poland
Togay Evrin, MD Department of Emergency Medicine, UFuK University Medical Faculty Dr Ridvan Ege Education and Research Hospital Ankara, Turkey
Andrzej Kurowski, PhD, MD Department of Anesthesiology, Cardinal Wyszynski National Institute of Cardiology Warsaw, Poland
Jolanta Majer, MD Department of Emergency Medicine, Holy Mary Memorial Provincial Specialist Hospital, Czestochowa, Poland
Katarzyna Karczewska, MD Anesthesiology and Intensive Care Unit, Mazovian Regional Hospital Radom, Poland
http://dx.doi.org/10.1016/j.ajem.2015.04.078 References
[1] Dong Y, Li G, Wu W, Su R, Shao Y. Lightwand-guided nasotracheal intubation in oromaxillofacial surgery patients with anticipated difficult airways: a comparison with blind nasal intubation. Int J Oral Maxillofac Surg 2013;42(9):1049–53.http:// dx.doi.org/10.1016/j.ijom.2013.01.027.
[2] Field-Ridley A, Sethi V, Murthi S, Nandalike K, Li ST. Utility offlexible fiberoptic bron-choscopy for critically ill pediatric patients: a systematic review. World J Crit Care Med 2015;4(1):77–88.http://dx.doi.org/10.5492/wjccm.v4.i1.77.
[3]Umutoglu T, Bakan M, Topuz U, Alver S, Ozturk E. Use of ETView Tracheoscopic Ven-tilation Tube® in airway management of a patient with tracheal injury. Minerva Anestesiol 2014;80(3):398–9.
[4] Barak M, Putilov V, Meretyk S, Halachmi S. ETView tracheoscopic ventilation tube for surveillance after tube position in patients undergoing percutaneous nephrolithotomy. Br J Anaesth 2010;104(4):501–4.http://dx.doi.org/10.1093/bja/ aeq024.
[5] Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guide-lines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circula-tion 2010;122(18 Suppl 3):S729–67.http://dx.doi.org/10.1161/CIRCULATIONAHA. 110.970988.
Peripartum cardiomyopathy in the ED
To the Editor,
We read with interest the review article recently published by McGregor et al[1]entitled“The pregnant heart: cardiac emergen-cies during pregnancy.” However, we have some concerns about the definition of peripartum cardiomyopathy (PPCM), which is a rare obstetric emergency. Presentation of PPCM in the emergency department is similar to that of patients presenting with heart fail-ure due to other causes[2]. Diagnosis of PPCM is often missed or de-layed because most of the signs and symptoms of normal pregnancy are similar to those of heart failure[2]. Peripartum cardiomyopathy 1099 Correspondence / American Journal of Emergency Medicine 33 (2015) 1093–1107
