Adam Levine - Academia.edu (original) (raw)
Papers by Adam Levine
Background: The incidence of cardiac arrests per year in the United States continues to increase,... more Background: The incidence of cardiac arrests per year in the United States continues to increase, yet in-hospital cardiac arrest survival rates significantly vary between hospitals. Current methods of training are expensive, time consuming, and difficult to scale, which necessitates improvements in advanced cardiac life support (ACLS) training. Virtual reality (VR) has been proposed as an alternative or adjunct to high-fidelity simulation (HFS) in several environments. No evaluations to date have explored the ability of a VR program to examine both technical and behavioral skills and demonstrate a cost comparison. Objective: This study aimed to explore the utility of a voice-based VR ACLS team leader refresher as compared with HFS. Methods: This prospective observational study performed at an academic institution consisted of 25 postgraduate year 2 residents. Participants were randomized to HFS or VR training and then crossed groups after a 2-week washout. Participants were graded on technical and nontechnical skills. Participants also completed self-assessments about the modules. Proctors were assessed for fatigue and task saturation, and cost analysis based on local economic data was performed. Results: A total of 23 of 25 participants were included in the scoring analysis. Fewer participants were familiar with VR compared with HFS (9/25, 36% vs 25/25, 100%; P<.001). Self-reported satisfaction and utilization scores were similar; however, significantly more participants felt HFS provided better feedback: 99 (IQR 89-100) vs 79 (IQR 71-88); P<.001. Technical scores were higher in the HFS group; however, nontechnical scores for decision making and communication were not significantly different between modalities. VR sessions were 21 (IQR 19-24) min shorter than HFS sessions, the National Aeronautics and Space Administration task load index scores for proctors were lower in each category, and VR sessions were estimated to be US $103.68 less expensive in a single-learner, single-session model. Conclusions: Utilization of a VR-based team leader refresher for ACLS skills is comparable with HFS in several areas, including learner satisfaction. The VR module was more cost-effective and was easier to proctor; however, HFS was better at delivering feedback to participants. Optimal education strategies likely contain elements of both modalities. Further studies are needed to examine the utility of VR-based environments at scale.
BJA: British Journal of Anaesthesia, Jul 1, 2016
Background: Non-operating room (non-OR) airway management has previously been identified as an ar... more Background: Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone vs with a resident partner when encountering simulated non-OR airway management scenarios. Methods: Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group). Results: Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 vs 5.5 out of 10; P<0.001) and PEA (8.5 vs 5.8 out of 10; P<0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 vs 23.5 s (P<0.001) and 13.3 vs 36.0 s (P<0.001), respectively]. Conclusions: Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method.
BJA: British Journal of Anaesthesia, Jul 1, 2016
Background: Non-operating room (non-OR) airway management has previously been identified as an ar... more Background: Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone vs with a resident partner when encountering simulated non-OR airway management scenarios. Methods: Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group). Results: Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 vs 5.5 out of 10; P<0.001) and PEA (8.5 vs 5.8 out of 10; P<0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 vs 23.5 s (P<0.001) and 13.3 vs 36.0 s (P<0.001), respectively]. Conclusions: Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method.
Comprehensive Healthcare Simulation, 2020
This new series focuses on the use of simulation in healthcare education, one of the most excitin... more This new series focuses on the use of simulation in healthcare education, one of the most exciting and significant innovations in healthcare teaching since Halsted put forth the paradigm of "see one, do one, teach one." Each volume focuses either on the use of simulation in teaching in a specific specialty or on a cross-cutting topic of broad interest, such as the development of a simulation center. The volumes stand alone and are also designed to complement Levine, DeMaria, Schwartz, and Sim, eds., The Comprehensive Textbook of Healthcare Simulation by providing detailed and practical guidance beyond the scope of the larger book and presenting the most up-to-date information available. Series Editors Drs. Adam I. Levine and Samuel DeMaria Jr. are affiliated with the
Medical Teacher, Apr 7, 2016
There is considerable controversy as to whether the simulator should die during high-fidelity sim... more There is considerable controversy as to whether the simulator should die during high-fidelity simulation (HFS). We sought to describe the physiologic and biochemical stress response induced by simulated patient death as well as the impact on long-term retention of Advanced Cardiovascular Life Support (ACLS) knowledge and skills. Twenty-six subjects received an American Heart Association (AHA) ACLS provider course. Following the course, subjects participated in HFS and were randomized to simulated death or survival. Heart rate and salivary cortisol (SC) and dihydroepiandrosterone (DHEA) were collected at this time. Subjects returned six months later for a follow-up simulation in which ACLS knowledge and skills were tested. For all participants, there was an increase in heart rate during simulation compared with baseline heart rate (+ 32 beats/minute), p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001. Similarly, SC and DHEA were higher compared with baseline levels (+ 0.115 μg/dL, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01 and + 97 pg/mL, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001, respectively). However, the only statistically significant difference between groups was an increase in heart rate response at the end of the simulation compared with baseline in the death group (+ 29.2 beats/minute versus + 18.5 beats/minute), p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05. There was no difference on long-term knowledge or skills. Learners experience stress during high-fidelity simulation; however, there does not appear to be a readily detectable difference or negative response to a simulated patient death compared with simulated survival.
PubMed, Oct 1, 2011
Background: The development of medical students' perceptions of different medical specialties is ... more Background: The development of medical students' perceptions of different medical specialties is based on many factors and influences their career choices and appreciation of other practitioners' knowledge and skills. The goal of this study was to determine if participation in a series of anesthesiologist-run, simulation-based physiology labs changed first year medical students' perceptions of anesthesiologists. Methods: One hundred first-year medical students were surveyed at random three months before completion of a simulation-based physiology lab run by anesthesiologists. All participants received the same survey instrument, which employed a 5-point Rating Scale to rate the appropriateness of several descriptive terms as they apply to a particular specialist or specialty. A post-simulation survey was performed to track changes in attitudes. Results: Response rates to the survey before and after the simulation labs were 75% and 97% (ofthe initial cohort responding), respectively. All students who filled out the post-simulation surveys had been exposed to anesthesiologists in the prior three months whereas none had interacted with surgeons in the interim. Nearly all had interacted with internal medicine specialists in that time period. No changes in the medical students' perceptions of surgeons or internal medicine specialists were evident. Statistically significant changes were found for most descriptors of anesthesiologists, with a trend towards a more favorable perception after the simulation program. Conclusions: Using a survey instrument containing descriptors of different medical specialists and specialties, we found an improved attitude towards anesthesiology after medical students participated in an anesthesiologist-run simulation-based physiology lab series. Given the importance of providing high quality medical education and attracting quality applicants to the field, integrati-on of anesthesiology staff into medical student courses at the non-clinical level appears useful.
Middle East journal of anaesthesiology, Jun 1, 2008
The increasing role of simulation in medical education has paralleled advancement of this technol... more The increasing role of simulation in medical education has paralleled advancement of this technology. Full environment simulation (FES) can be employed to effectively replicate rare medical catastrophes with exacting realism. It has been suggested that emotion can significantly enhance learning by producing memories that are processed and stored via the amygdaloid complex which is relatively impervious to extinction and thus forgetting. Theoretically the addition of emotional content to simulated crises during FES can be used to affect such changes in the participants and thus facilitate learning. We discuss the theoretic benefit and the use of FES with emotional enhancement as it relates to improved memory and learning.
ABSTRACT Checklists have been shown to reduce patient complications, improve communication in the... more ABSTRACT Checklists have been shown to reduce patient complications, improve communication in the operating room, and improve the management of simulated operating room crises. Using a randomized, controlled, observer-blinded design, we compared performance of anesthesiology residents in a simulated operating room using a checklist in completing a thorough pre-anesthetic induction evaluation and setup, to residents with no checklist. The checklist was implemented through a "hard stop" in the simulated electronic medical record. Data for 24 CA-1 residents show a statistically significant difference in performance in pre-anesthetic setup and evaluation as scored by blinded raters, with the checklist group performing better.
Seminars in Cardiothoracic and Vascular Anesthesia, Sep 12, 2017
We present a case of a patient with complete tracheal dehiscence and multiple false passages afte... more We present a case of a patient with complete tracheal dehiscence and multiple false passages after recent tracheal resection and anastomosis. Loss of tracheal continuity after disruption of anastomosis with distal stump retraction presents a unique anesthetic challenge given lack of access to the trachea and the need for adequate anesthesia and analgesia for surgical neck dissection. Traditional airway management, including awake fiberoptic intubation, intubation via direct laryngoscopy, needle cricothyrotomy, and awake tracheostomy are not viable options. Using total intravenous anesthesia with spontaneous ventilation, surgeons dissected the neck, retrieved the distal tracheal stump, repaired the trachea, and formalized the tracheostomy. We highlight the importance of recognizing the symptoms of a tracheal rupture, understanding the extreme limitation of securing the airway with traditional techniques, and discuss the alternative techniques including use of extracorporeal membrane oxygenation to avoid airway management. Awareness of increased mortality risk with tracheal reoperation and the significance of close communication between the anesthesiologists, the surgeons, and the patient is necessary for successful management.
BJA: British Journal of Anaesthesia, May 1, 2015
† Medical simulation offers learning opportunities without risk to patient care. † Simulation sce... more † Medical simulation offers learning opportunities without risk to patient care. † Simulation scenarios reproduce physiological pertubations and critical incidents. † Premature or simplistic resolution of a critical incident may limit solid learning. † Failure, if coupled with supportive teaching, can impact positively on learning. Background. Anaesthetists may fail to recognize and manage certain rare intraoperative events. Simulation has been shown to be an effective educational adjunct to typical operating room-based education to train for these events. It is yet unclear, however, why simulation has any benefit. We hypothesize that learners who are allowed to manage a scenario independently and allowed to fail, thus causing simulated morbidity, will consequently perform better when re-exposed to a similar scenario. Methods. Using a randomized, controlled, observer-blinded design, 24 first-year residents were exposed to an oxygen pipeline contamination scenario, either where patient harm occurred (independent group, n¼12) or where a simulated attending anaesthetist intervened to prevent harm (supervised group, n¼12). Residents were brought back 6 months later and exposed to a different scenario (pipeline contamination) with the same end point. Participants' proper treatment, time to diagnosis, and non-technical skills (measured using the Anaesthetists' Non-Technical Skills Checklist, ANTS) were measured. Results. No participants provided proper treatment in the initial exposure. In the repeat encounter 6 months later, 67% in the independent group vs 17% in the supervised group resumed adequate oxygen delivery (P¼0.013). The independent group also had better ANTS scores [median (interquartile range): 42.3 (31.5-53.1) vs 31.3 (21.6-41), P¼0.015]. There was no difference in time to treatment if proper management was provided [602 (490-820) vs 610 (420-800) s, P¼0.79]. Conclusions. Allowing residents to practise independently in the simulation laboratory, and subsequently, allowing them to fail, can be an important part of simulation-based learning. This is not feasible in real clinical practice but appears to have improved resident performance in this study. The purposeful use of independent practice and its potentially negative outcomes thus sets simulation-based learning apart from traditional operating room learning.
Journal of Critical Care, Jun 1, 2008
Although rarely thought of as simulations by anesthesia educators, the use of standardized patien... more Although rarely thought of as simulations by anesthesia educators, the use of standardized patients to simulate clinical encounters spans 4 decades (Mt Sinai J Med. 1996;63:241-249; J Am Med Assoc. 1997;278:790-791; Int J Dermatol. 1999;38:893-894). Although its efficacy for education and evaluation in the medical community has been well established through extensive research, there is a distinct dearth in the literature in its use for anesthesia trainee education and evaluation. In this article, we discuss this simulation modality via a historic review, its current application in competency assessment, and its use in anesthesiology education and evaluation. We conclude with a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;how to guide&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; to facilitate those considering including standardized patient simulations into their anesthesia training or simulation curriculum.
Journal of Clinical Anesthesia, Feb 1, 2012
In 2010, the American Board of Anesthesiology instituted a new Maintenance of Certification in An... more In 2010, the American Board of Anesthesiology instituted a new Maintenance of Certification in Anesthesiology (MOCA) Part IV activity requiring diplomates to attend and self-reflect on a simulation-based course in an American Society of Anesthesiologists-endorsed program. Although there are certain course requirements, much of the curriculum and structure of these MOCA activities is left to the discretion of the participating endorsed program. The ideal course would emphasize multimodality simulation-based activities that optimize diplomate education and satisfaction, while economizing faculty requirements. We describe of our course structure and content as a potentially useful template.
Medical Education, Sep 30, 2010
Journal of Critical Care, Jun 1, 2008
M edical training has turned its attention to the skills needed for patient management and increa... more M edical training has turned its attention to the skills needed for patient management and increased patient safety. Anesthesia residency training combines practice in the operating room and didactic learning along with time in the anesthesia Comment by Craig R. Bailey, FRCA
Journal of Clinical Anesthesia, Aug 1, 2008
There is a high rate of relapse among anesthesia residents attempting to re-enter clinical anesth... more There is a high rate of relapse among anesthesia residents attempting to re-enter clinical anesthesia training programs after completing treatment for opioid addiction. Individuals may return to clinical practice after a short period of treatment only to relapse into active addiction, and for the opioid addicted anesthesia resident, this often results in death. The objective of this study was to determine weather or not a period of time away from clinical practice after treatment would reduce the rate of relapse by allowing the individual to concentrate on recovery in the critical first year after treatment, during which the majority of relapses occur. 5 residents identified as being addicted to a controlled substance were removed from residency training and offered treatment. Prior to returning to residency training they were required to complete a post-treatment program involving no less than 12 months of work in the anesthesia simulator, followed by a graded re-introduction into the clinical practice of anesthesia. Academic anesthesia practice in a large teaching hospital. Of the 5 residents who participated in the program, 3 (60%) successfully completed their residency program and their 5 year monitoring contract, and entered the anesthesia workforce as attending anesthesiologists. The treatment of addicted physicians can be successful, and return of the highly motivated individual to the clinical practice of Anesthesiology is a realistic goal, but this reintroduction must be undertaken in a careful, stepwise fashion. A full understanding of the disease process, the potential for relapse, and the implications of too rapid a return to practice must be taken into careful consideration.
Simulation in healthcare : journal of the Society for Simulation in Healthcare, Dec 1, 2013
ABSTRACT Introduction/Background: Surgical safety checklists have been shown to reduce patient co... more ABSTRACT Introduction/Background: Surgical safety checklists have been shown to reduce patient complications and improve communication in the operating room.1,2 Checklists have also been shown to improve the management of operating room crises in high fidelity simulation studies.3,4 The pre-anesthetic induction period has been identified as a time in which medical errors can occur.5 The Anesthesia Patient Safety Foundation (APSF) has developed a pre-anesthetic induction patient safety (PIPS) checklist.6 Using full environment simulation (FES), we hope to detect a significant reduction in missed steps during the pre-anesthetic set up when using this checklist. All participants in this study will be exposed to the same clinical scenario but one group will experience a "hard stop" in the documentation workflow. We hope to use the Results of this study to validate the simulated environment as an effective and novel way to inform the implementation and further study of patient safety and quality improvement initiatives that may be difficult to clinically test. Methods: Using a randomized, controlled, observer-blinded design, we compare performance of anesthesiology residents using the APSF PIPS checklist in completing a thorough pre-anesthetic induction evaluation and setup, to residents with no checklist.6 The study is performed using the METI high-fidelity simulator. The simulated OR is set up to represent a previously used anesthesia machine/cart that has not been set up for a new anesthetic, and is missing the components highlighted in the PIPS checklist. The residents will be called in to provide anesthesia for a case that was booked initially as a case only requiring local anesthesia. The surgeon will create time pressure for the residents to induce anesthesia prematurely in this entirely elective setting. In the experimental group, the electronic medical record will create a "hard stop" in which the APSF PIPS checklist is displayed and must be checked and signed off on before any further documentation of the anesthetic can occur. In the control group, this "hard stop" will not be present in the electronic medical record. The simulation will end when the resident provides any medication to the patient, and missed steps will be recorded at that time. The hypothesis is that the required use of the APSF PIPS checklist prevents missed steps in the pre-anesthetic set up under time pressure in a simulated operating room. Results: Conclusion: Our study illustrates the importance of the simulated environment in evaluation of new patient safety and quality improvement initiatives as the specific situations in which such initiatives are likely to increase patient safety can never be ethically or successfully replicated in real life. References: 1. Haynes AB, Weiser TG, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. 2. de Vries EN, Prins HA, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010 Nov 11;363(20):1928-37. 3. Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013 Jan 17;368(3):246-53. 4. Neal JM, Hsiung RL, Mulroy MF, et al. ASRA checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):8-15. 5. Demaria S, Blasius K, Neustein SM: Missed steps in the preanesthetic set-up. Anesthesia and analgesia 2011; 113:84A[pounds]AE'A[right pointing guillemet]8/ 6. APSF Survey Helps To Establish Pre-Induction Checklist. (2013). Retrieved from http://www.apsf.org/newsletters/html/2013/spring/02checklist.htm. Disclosures: Mylan Specialties.
Anesthesia & Analgesia, Feb 1, 2015
Functional endoscopic sinus surgery (FESS) is the mainstay of surgical treatment for sinonasal di... more Functional endoscopic sinus surgery (FESS) is the mainstay of surgical treatment for sinonasal disease. This surgery carries certain risks. Most of these risks relate to the quality of the surgical field. Thus, mechanisms by which the surgical field can be improved are important to study. We sought to determine whether positive end-expiratory pressure (PEEP) had a deleterious effect on the quality of the surgical field in patients undergoing primary FESS. Forty-seven patients were randomized to a ventilation strategy using either 5 cm H2O of PEEP or zero added PEEP. The quality of the surgical field was measured every 15 minutes using a validated surgical scoring method. The addition of PEEP did not have any measurable effect on the surgical field scores after onset of surgery (odds ratio [OR] (95% confidence interval [CI]) = 1.06 (0.44-2.58), P = 0.895 for side 1; OR (95% CI) = 0.56 (0.16-1.93), P = 0.356 for side 2). The peak inspiratory pressure did have an effect on surgical grades. Every cm H2O of added pressure over 15 cm H2O total pressure contributing to increased odds of higher surgical field score. For each cm H2O increase in inspiratory pressure above 15cm H2O increased the surgical field score (OR [95% CI] 1.13 [1.04-1.22], P = 0.002). During FESS surgery if PEEP is added, it is important to keep the mean inspiratory pressure below 15cm H2O to avoid worsening surgical field conditions.
Anesthesia & Analgesia, Feb 1, 2010
Remifentanil is a potent micro-opioid receptor agonist that produces intense analgesia. This anil... more Remifentanil is a potent micro-opioid receptor agonist that produces intense analgesia. This anilidopiperidine analog of fentanyl was approved by the United States Food and Drug Administration and became commercially available in the United States in 1997. Because of its unique chemical structure, remifentanil must be reconstituted; it has a rapid onset, and because of ester hydrolysis, it has a rapid rate of degradation. Although remifentanil&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s package insert warns against the potential for addiction, because of its rapid rate of degradation there was little concern that health care workers would abuse this drug. Herein, we report a case of intranasal remifentanil abuse by an anesthesiology resident.
Journal of Critical Care, Jun 1, 2008
The increasing role of simulation in medical education has paralleled the advancement of this tec... more The increasing role of simulation in medical education has paralleled the advancement of this technology. Full environment simulation (FES) can be used to effectively replicate rare medical catastrophes with exacting realism. It has been suggested that emotion can significantly enhance learning by producing memories that are processed and stored via the amygdaloid complex, which are relatively impervious to extinction and thus forgetting. Theoretically, the addition of emotional content to simulated crises during FES can be used to affect emotional changes in the participants and thus facilitate learning. Here, we discuss the theoretical benefit and the use of FES with emotional enhancement as it relates to improved memory and learning.
Comprehensive Healthcare Simulation: Anesthesiology, 2019
Background: The incidence of cardiac arrests per year in the United States continues to increase,... more Background: The incidence of cardiac arrests per year in the United States continues to increase, yet in-hospital cardiac arrest survival rates significantly vary between hospitals. Current methods of training are expensive, time consuming, and difficult to scale, which necessitates improvements in advanced cardiac life support (ACLS) training. Virtual reality (VR) has been proposed as an alternative or adjunct to high-fidelity simulation (HFS) in several environments. No evaluations to date have explored the ability of a VR program to examine both technical and behavioral skills and demonstrate a cost comparison. Objective: This study aimed to explore the utility of a voice-based VR ACLS team leader refresher as compared with HFS. Methods: This prospective observational study performed at an academic institution consisted of 25 postgraduate year 2 residents. Participants were randomized to HFS or VR training and then crossed groups after a 2-week washout. Participants were graded on technical and nontechnical skills. Participants also completed self-assessments about the modules. Proctors were assessed for fatigue and task saturation, and cost analysis based on local economic data was performed. Results: A total of 23 of 25 participants were included in the scoring analysis. Fewer participants were familiar with VR compared with HFS (9/25, 36% vs 25/25, 100%; P<.001). Self-reported satisfaction and utilization scores were similar; however, significantly more participants felt HFS provided better feedback: 99 (IQR 89-100) vs 79 (IQR 71-88); P<.001. Technical scores were higher in the HFS group; however, nontechnical scores for decision making and communication were not significantly different between modalities. VR sessions were 21 (IQR 19-24) min shorter than HFS sessions, the National Aeronautics and Space Administration task load index scores for proctors were lower in each category, and VR sessions were estimated to be US $103.68 less expensive in a single-learner, single-session model. Conclusions: Utilization of a VR-based team leader refresher for ACLS skills is comparable with HFS in several areas, including learner satisfaction. The VR module was more cost-effective and was easier to proctor; however, HFS was better at delivering feedback to participants. Optimal education strategies likely contain elements of both modalities. Further studies are needed to examine the utility of VR-based environments at scale.
BJA: British Journal of Anaesthesia, Jul 1, 2016
Background: Non-operating room (non-OR) airway management has previously been identified as an ar... more Background: Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone vs with a resident partner when encountering simulated non-OR airway management scenarios. Methods: Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group). Results: Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 vs 5.5 out of 10; P<0.001) and PEA (8.5 vs 5.8 out of 10; P<0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 vs 23.5 s (P<0.001) and 13.3 vs 36.0 s (P<0.001), respectively]. Conclusions: Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method.
BJA: British Journal of Anaesthesia, Jul 1, 2016
Background: Non-operating room (non-OR) airway management has previously been identified as an ar... more Background: Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone vs with a resident partner when encountering simulated non-OR airway management scenarios. Methods: Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group). Results: Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 vs 5.5 out of 10; P<0.001) and PEA (8.5 vs 5.8 out of 10; P<0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 vs 23.5 s (P<0.001) and 13.3 vs 36.0 s (P<0.001), respectively]. Conclusions: Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method.
Comprehensive Healthcare Simulation, 2020
This new series focuses on the use of simulation in healthcare education, one of the most excitin... more This new series focuses on the use of simulation in healthcare education, one of the most exciting and significant innovations in healthcare teaching since Halsted put forth the paradigm of "see one, do one, teach one." Each volume focuses either on the use of simulation in teaching in a specific specialty or on a cross-cutting topic of broad interest, such as the development of a simulation center. The volumes stand alone and are also designed to complement Levine, DeMaria, Schwartz, and Sim, eds., The Comprehensive Textbook of Healthcare Simulation by providing detailed and practical guidance beyond the scope of the larger book and presenting the most up-to-date information available. Series Editors Drs. Adam I. Levine and Samuel DeMaria Jr. are affiliated with the
Medical Teacher, Apr 7, 2016
There is considerable controversy as to whether the simulator should die during high-fidelity sim... more There is considerable controversy as to whether the simulator should die during high-fidelity simulation (HFS). We sought to describe the physiologic and biochemical stress response induced by simulated patient death as well as the impact on long-term retention of Advanced Cardiovascular Life Support (ACLS) knowledge and skills. Twenty-six subjects received an American Heart Association (AHA) ACLS provider course. Following the course, subjects participated in HFS and were randomized to simulated death or survival. Heart rate and salivary cortisol (SC) and dihydroepiandrosterone (DHEA) were collected at this time. Subjects returned six months later for a follow-up simulation in which ACLS knowledge and skills were tested. For all participants, there was an increase in heart rate during simulation compared with baseline heart rate (+ 32 beats/minute), p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001. Similarly, SC and DHEA were higher compared with baseline levels (+ 0.115 μg/dL, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01 and + 97 pg/mL, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001, respectively). However, the only statistically significant difference between groups was an increase in heart rate response at the end of the simulation compared with baseline in the death group (+ 29.2 beats/minute versus + 18.5 beats/minute), p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05. There was no difference on long-term knowledge or skills. Learners experience stress during high-fidelity simulation; however, there does not appear to be a readily detectable difference or negative response to a simulated patient death compared with simulated survival.
PubMed, Oct 1, 2011
Background: The development of medical students' perceptions of different medical specialties is ... more Background: The development of medical students' perceptions of different medical specialties is based on many factors and influences their career choices and appreciation of other practitioners' knowledge and skills. The goal of this study was to determine if participation in a series of anesthesiologist-run, simulation-based physiology labs changed first year medical students' perceptions of anesthesiologists. Methods: One hundred first-year medical students were surveyed at random three months before completion of a simulation-based physiology lab run by anesthesiologists. All participants received the same survey instrument, which employed a 5-point Rating Scale to rate the appropriateness of several descriptive terms as they apply to a particular specialist or specialty. A post-simulation survey was performed to track changes in attitudes. Results: Response rates to the survey before and after the simulation labs were 75% and 97% (ofthe initial cohort responding), respectively. All students who filled out the post-simulation surveys had been exposed to anesthesiologists in the prior three months whereas none had interacted with surgeons in the interim. Nearly all had interacted with internal medicine specialists in that time period. No changes in the medical students' perceptions of surgeons or internal medicine specialists were evident. Statistically significant changes were found for most descriptors of anesthesiologists, with a trend towards a more favorable perception after the simulation program. Conclusions: Using a survey instrument containing descriptors of different medical specialists and specialties, we found an improved attitude towards anesthesiology after medical students participated in an anesthesiologist-run simulation-based physiology lab series. Given the importance of providing high quality medical education and attracting quality applicants to the field, integrati-on of anesthesiology staff into medical student courses at the non-clinical level appears useful.
Middle East journal of anaesthesiology, Jun 1, 2008
The increasing role of simulation in medical education has paralleled advancement of this technol... more The increasing role of simulation in medical education has paralleled advancement of this technology. Full environment simulation (FES) can be employed to effectively replicate rare medical catastrophes with exacting realism. It has been suggested that emotion can significantly enhance learning by producing memories that are processed and stored via the amygdaloid complex which is relatively impervious to extinction and thus forgetting. Theoretically the addition of emotional content to simulated crises during FES can be used to affect such changes in the participants and thus facilitate learning. We discuss the theoretic benefit and the use of FES with emotional enhancement as it relates to improved memory and learning.
ABSTRACT Checklists have been shown to reduce patient complications, improve communication in the... more ABSTRACT Checklists have been shown to reduce patient complications, improve communication in the operating room, and improve the management of simulated operating room crises. Using a randomized, controlled, observer-blinded design, we compared performance of anesthesiology residents in a simulated operating room using a checklist in completing a thorough pre-anesthetic induction evaluation and setup, to residents with no checklist. The checklist was implemented through a "hard stop" in the simulated electronic medical record. Data for 24 CA-1 residents show a statistically significant difference in performance in pre-anesthetic setup and evaluation as scored by blinded raters, with the checklist group performing better.
Seminars in Cardiothoracic and Vascular Anesthesia, Sep 12, 2017
We present a case of a patient with complete tracheal dehiscence and multiple false passages afte... more We present a case of a patient with complete tracheal dehiscence and multiple false passages after recent tracheal resection and anastomosis. Loss of tracheal continuity after disruption of anastomosis with distal stump retraction presents a unique anesthetic challenge given lack of access to the trachea and the need for adequate anesthesia and analgesia for surgical neck dissection. Traditional airway management, including awake fiberoptic intubation, intubation via direct laryngoscopy, needle cricothyrotomy, and awake tracheostomy are not viable options. Using total intravenous anesthesia with spontaneous ventilation, surgeons dissected the neck, retrieved the distal tracheal stump, repaired the trachea, and formalized the tracheostomy. We highlight the importance of recognizing the symptoms of a tracheal rupture, understanding the extreme limitation of securing the airway with traditional techniques, and discuss the alternative techniques including use of extracorporeal membrane oxygenation to avoid airway management. Awareness of increased mortality risk with tracheal reoperation and the significance of close communication between the anesthesiologists, the surgeons, and the patient is necessary for successful management.
BJA: British Journal of Anaesthesia, May 1, 2015
† Medical simulation offers learning opportunities without risk to patient care. † Simulation sce... more † Medical simulation offers learning opportunities without risk to patient care. † Simulation scenarios reproduce physiological pertubations and critical incidents. † Premature or simplistic resolution of a critical incident may limit solid learning. † Failure, if coupled with supportive teaching, can impact positively on learning. Background. Anaesthetists may fail to recognize and manage certain rare intraoperative events. Simulation has been shown to be an effective educational adjunct to typical operating room-based education to train for these events. It is yet unclear, however, why simulation has any benefit. We hypothesize that learners who are allowed to manage a scenario independently and allowed to fail, thus causing simulated morbidity, will consequently perform better when re-exposed to a similar scenario. Methods. Using a randomized, controlled, observer-blinded design, 24 first-year residents were exposed to an oxygen pipeline contamination scenario, either where patient harm occurred (independent group, n¼12) or where a simulated attending anaesthetist intervened to prevent harm (supervised group, n¼12). Residents were brought back 6 months later and exposed to a different scenario (pipeline contamination) with the same end point. Participants' proper treatment, time to diagnosis, and non-technical skills (measured using the Anaesthetists' Non-Technical Skills Checklist, ANTS) were measured. Results. No participants provided proper treatment in the initial exposure. In the repeat encounter 6 months later, 67% in the independent group vs 17% in the supervised group resumed adequate oxygen delivery (P¼0.013). The independent group also had better ANTS scores [median (interquartile range): 42.3 (31.5-53.1) vs 31.3 (21.6-41), P¼0.015]. There was no difference in time to treatment if proper management was provided [602 (490-820) vs 610 (420-800) s, P¼0.79]. Conclusions. Allowing residents to practise independently in the simulation laboratory, and subsequently, allowing them to fail, can be an important part of simulation-based learning. This is not feasible in real clinical practice but appears to have improved resident performance in this study. The purposeful use of independent practice and its potentially negative outcomes thus sets simulation-based learning apart from traditional operating room learning.
Journal of Critical Care, Jun 1, 2008
Although rarely thought of as simulations by anesthesia educators, the use of standardized patien... more Although rarely thought of as simulations by anesthesia educators, the use of standardized patients to simulate clinical encounters spans 4 decades (Mt Sinai J Med. 1996;63:241-249; J Am Med Assoc. 1997;278:790-791; Int J Dermatol. 1999;38:893-894). Although its efficacy for education and evaluation in the medical community has been well established through extensive research, there is a distinct dearth in the literature in its use for anesthesia trainee education and evaluation. In this article, we discuss this simulation modality via a historic review, its current application in competency assessment, and its use in anesthesiology education and evaluation. We conclude with a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;how to guide&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; to facilitate those considering including standardized patient simulations into their anesthesia training or simulation curriculum.
Journal of Clinical Anesthesia, Feb 1, 2012
In 2010, the American Board of Anesthesiology instituted a new Maintenance of Certification in An... more In 2010, the American Board of Anesthesiology instituted a new Maintenance of Certification in Anesthesiology (MOCA) Part IV activity requiring diplomates to attend and self-reflect on a simulation-based course in an American Society of Anesthesiologists-endorsed program. Although there are certain course requirements, much of the curriculum and structure of these MOCA activities is left to the discretion of the participating endorsed program. The ideal course would emphasize multimodality simulation-based activities that optimize diplomate education and satisfaction, while economizing faculty requirements. We describe of our course structure and content as a potentially useful template.
Medical Education, Sep 30, 2010
Journal of Critical Care, Jun 1, 2008
M edical training has turned its attention to the skills needed for patient management and increa... more M edical training has turned its attention to the skills needed for patient management and increased patient safety. Anesthesia residency training combines practice in the operating room and didactic learning along with time in the anesthesia Comment by Craig R. Bailey, FRCA
Journal of Clinical Anesthesia, Aug 1, 2008
There is a high rate of relapse among anesthesia residents attempting to re-enter clinical anesth... more There is a high rate of relapse among anesthesia residents attempting to re-enter clinical anesthesia training programs after completing treatment for opioid addiction. Individuals may return to clinical practice after a short period of treatment only to relapse into active addiction, and for the opioid addicted anesthesia resident, this often results in death. The objective of this study was to determine weather or not a period of time away from clinical practice after treatment would reduce the rate of relapse by allowing the individual to concentrate on recovery in the critical first year after treatment, during which the majority of relapses occur. 5 residents identified as being addicted to a controlled substance were removed from residency training and offered treatment. Prior to returning to residency training they were required to complete a post-treatment program involving no less than 12 months of work in the anesthesia simulator, followed by a graded re-introduction into the clinical practice of anesthesia. Academic anesthesia practice in a large teaching hospital. Of the 5 residents who participated in the program, 3 (60%) successfully completed their residency program and their 5 year monitoring contract, and entered the anesthesia workforce as attending anesthesiologists. The treatment of addicted physicians can be successful, and return of the highly motivated individual to the clinical practice of Anesthesiology is a realistic goal, but this reintroduction must be undertaken in a careful, stepwise fashion. A full understanding of the disease process, the potential for relapse, and the implications of too rapid a return to practice must be taken into careful consideration.
Simulation in healthcare : journal of the Society for Simulation in Healthcare, Dec 1, 2013
ABSTRACT Introduction/Background: Surgical safety checklists have been shown to reduce patient co... more ABSTRACT Introduction/Background: Surgical safety checklists have been shown to reduce patient complications and improve communication in the operating room.1,2 Checklists have also been shown to improve the management of operating room crises in high fidelity simulation studies.3,4 The pre-anesthetic induction period has been identified as a time in which medical errors can occur.5 The Anesthesia Patient Safety Foundation (APSF) has developed a pre-anesthetic induction patient safety (PIPS) checklist.6 Using full environment simulation (FES), we hope to detect a significant reduction in missed steps during the pre-anesthetic set up when using this checklist. All participants in this study will be exposed to the same clinical scenario but one group will experience a "hard stop" in the documentation workflow. We hope to use the Results of this study to validate the simulated environment as an effective and novel way to inform the implementation and further study of patient safety and quality improvement initiatives that may be difficult to clinically test. Methods: Using a randomized, controlled, observer-blinded design, we compare performance of anesthesiology residents using the APSF PIPS checklist in completing a thorough pre-anesthetic induction evaluation and setup, to residents with no checklist.6 The study is performed using the METI high-fidelity simulator. The simulated OR is set up to represent a previously used anesthesia machine/cart that has not been set up for a new anesthetic, and is missing the components highlighted in the PIPS checklist. The residents will be called in to provide anesthesia for a case that was booked initially as a case only requiring local anesthesia. The surgeon will create time pressure for the residents to induce anesthesia prematurely in this entirely elective setting. In the experimental group, the electronic medical record will create a "hard stop" in which the APSF PIPS checklist is displayed and must be checked and signed off on before any further documentation of the anesthetic can occur. In the control group, this "hard stop" will not be present in the electronic medical record. The simulation will end when the resident provides any medication to the patient, and missed steps will be recorded at that time. The hypothesis is that the required use of the APSF PIPS checklist prevents missed steps in the pre-anesthetic set up under time pressure in a simulated operating room. Results: Conclusion: Our study illustrates the importance of the simulated environment in evaluation of new patient safety and quality improvement initiatives as the specific situations in which such initiatives are likely to increase patient safety can never be ethically or successfully replicated in real life. References: 1. Haynes AB, Weiser TG, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. 2. de Vries EN, Prins HA, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010 Nov 11;363(20):1928-37. 3. Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013 Jan 17;368(3):246-53. 4. Neal JM, Hsiung RL, Mulroy MF, et al. ASRA checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):8-15. 5. Demaria S, Blasius K, Neustein SM: Missed steps in the preanesthetic set-up. Anesthesia and analgesia 2011; 113:84A[pounds]AE'A[right pointing guillemet]8/ 6. APSF Survey Helps To Establish Pre-Induction Checklist. (2013). Retrieved from http://www.apsf.org/newsletters/html/2013/spring/02checklist.htm. Disclosures: Mylan Specialties.
Anesthesia & Analgesia, Feb 1, 2015
Functional endoscopic sinus surgery (FESS) is the mainstay of surgical treatment for sinonasal di... more Functional endoscopic sinus surgery (FESS) is the mainstay of surgical treatment for sinonasal disease. This surgery carries certain risks. Most of these risks relate to the quality of the surgical field. Thus, mechanisms by which the surgical field can be improved are important to study. We sought to determine whether positive end-expiratory pressure (PEEP) had a deleterious effect on the quality of the surgical field in patients undergoing primary FESS. Forty-seven patients were randomized to a ventilation strategy using either 5 cm H2O of PEEP or zero added PEEP. The quality of the surgical field was measured every 15 minutes using a validated surgical scoring method. The addition of PEEP did not have any measurable effect on the surgical field scores after onset of surgery (odds ratio [OR] (95% confidence interval [CI]) = 1.06 (0.44-2.58), P = 0.895 for side 1; OR (95% CI) = 0.56 (0.16-1.93), P = 0.356 for side 2). The peak inspiratory pressure did have an effect on surgical grades. Every cm H2O of added pressure over 15 cm H2O total pressure contributing to increased odds of higher surgical field score. For each cm H2O increase in inspiratory pressure above 15cm H2O increased the surgical field score (OR [95% CI] 1.13 [1.04-1.22], P = 0.002). During FESS surgery if PEEP is added, it is important to keep the mean inspiratory pressure below 15cm H2O to avoid worsening surgical field conditions.
Anesthesia & Analgesia, Feb 1, 2010
Remifentanil is a potent micro-opioid receptor agonist that produces intense analgesia. This anil... more Remifentanil is a potent micro-opioid receptor agonist that produces intense analgesia. This anilidopiperidine analog of fentanyl was approved by the United States Food and Drug Administration and became commercially available in the United States in 1997. Because of its unique chemical structure, remifentanil must be reconstituted; it has a rapid onset, and because of ester hydrolysis, it has a rapid rate of degradation. Although remifentanil&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s package insert warns against the potential for addiction, because of its rapid rate of degradation there was little concern that health care workers would abuse this drug. Herein, we report a case of intranasal remifentanil abuse by an anesthesiology resident.
Journal of Critical Care, Jun 1, 2008
The increasing role of simulation in medical education has paralleled the advancement of this tec... more The increasing role of simulation in medical education has paralleled the advancement of this technology. Full environment simulation (FES) can be used to effectively replicate rare medical catastrophes with exacting realism. It has been suggested that emotion can significantly enhance learning by producing memories that are processed and stored via the amygdaloid complex, which are relatively impervious to extinction and thus forgetting. Theoretically, the addition of emotional content to simulated crises during FES can be used to affect emotional changes in the participants and thus facilitate learning. Here, we discuss the theoretical benefit and the use of FES with emotional enhancement as it relates to improved memory and learning.
Comprehensive Healthcare Simulation: Anesthesiology, 2019