The practical management of emergencies in primary care: Taking simulation out of the classroom and into real-life environments

Life threatening emergencies in the community are relatively infrequent and therefore provide a challenge for doctors in keeping up-to-date and maintaining confidence. Training in managing emergencies typically takes place through role play and classroom based simulation. In this project, we took simulation out of the classroom and into community environments where emergencies actually occur creating 'real-life' scenarios. These included the practical management of meningitis, anaphylaxis, hypoglycaemia, convulsions and cardiac arrest. Doctors had to find and utilize the equipment in their surgeries and were asked to physically draw up the appropriate medication. The simulation training was led by a GP and a Consultant in Intensive Care Medicine. Participants' confidence in managing emergencies significantly increased after the workshops. Qualitative feedback illustrated the need for more simulation based learning: "I hope this can be done regularly as it will make a huge difference to patient care", "Excellent - life like to make more memorable", "Good to use the actual surgery equipment". Many of the participants knew the theory of what to do but lacked the practical skills to efficiently manage emergency scenarios. Training doctors through simulation needs to be taken out of the classroom and into real life environments. This is particularly important for 'time critical illnesses' where delays can have a direct impact on morbidity and mortality

Managing emergencies in primary care: does real-world simulation-based training have any lasting impact?

General Practitioners (GPs) have a responsibility to provide prompt and effective care when attending to life threatening emergencies in their GP surgeries. Primary care staff undertake mandatory, annual basic life support training. However, most emergencies are peri-arrest situations, and this is an area where GPs lack confidence and competence [1, 2]. The importance of effective, early intervention in peri-arrest scenarios was highlighted by the NCEPOD report “Time to Intervene (2012)” [3]. This report suggested that better early assessment and intervention may have prevented progression to cardiorespiratory arrest. GPs need to be equipped to manage ‘time critical’ emergencies, particularly as GP surgeries are deemed a place of safety and 999 ambulances can be redirected to other emergencies, thereby delaying transfer to secondary care for patients in GP settings. In previous work, we demonstrated that GPs’ confidence in managing time critical emergencies was initially low, and significantly improved immediately after attending ‘real-world’, simulation based workshops [1]. The value of real-world, in-house simulation based training has also been shown to increase “practical preparedness” in the context of resuscitation training (4). However, there is relatively little data regarding the long term value of simulation based training in primary care (5). In the current paper, we assessed whether our workshops had any longer-term benefit on participants’ confidence in managing emergencies and if it led to any changes in clinical practice

21st century fisheries management: a spatio-temporally explicit tariff-based approach combining multiple drivers and incentivising responsible fishing

Abstract Kraak, S. B. M., Reid, D. G., Gerritsen, H. D., Kelly, C. J., Fitzpatrick, M., Codling, E. A., and Rogan, E. 2012. 21st century fisheries management: a spatio-temporally explicit tariff-based approach combining multiple drivers and incentivising responsible fishing. – ICES Journal of Marine Science, 69: 590–601. Traditionally fisheries management has focused on biomass and mortality, expressed annually and across large management units. However, because fish abundance varies at much smaller spatio-temporal scales, fishing mortality can potentially be controlled more effectively if managed at finer scale. The ecosystem approach requires more indicators at finer scales as well. Incorporating ecosystem targets would need additional management tools with potentially conflicting results. We present a simple, integrated, management approach that provides incentives for “good behaviour”. Fishers would be given a number of fishing-impact credits, called real-time incentives (RTIs), to spend according to spatio-temporally varying tariffs per fishing day. RTI quotas and tariffs could be based on commercial stocks and ecosystem targets. Fishers could choose how to spend their RTIs, e.g. by limited fishing in high-catch or sensitive areas or by fishing longer in lower-catch or less sensitive areas. The RTI system does not prescribe and forbid, but instead allows fishers to fish wherever and whenever they want; ecosystem costs are internalized and fishers have to take them into account in their business decisions. We envisage no need for traditional landings or catch quotas for the fleets while operating under the scheme. The approach could facilitate further devolution of responsibility to industry.</jats:p

Quantifying transport energy efficiency savings

The importance of quantifying energy savings and improvement in energy efficiency for each sector of the economy is now widely recognized in order to demonstrate progress towards targets and compliance with legal obligations. The focus of this paper is specifically on evaluating energy efficiency in transport using the ODEX methodology. More detailed data has recently become available on transport energy trends and the underlying factors that allow the authors improve the calculation of Ireland’s transport ODEX. Through data mining of administrative databases mileage, volume, age, engine type and size data are available at a disaggregated level for each mode of road transport. In particular this paper examines private car energy efficiency, quantifying the change arising from improved data. There was an overall slight improvement (0.71 percentage points) in the Irish private car ODEX when both proposed changes of using MJ/km as the unit consumption measure and modeling the stock by vintage were applied. The overall effect of the revised transport ODEX calculation does not show a significant increase in energy savings associated with the value of the ODEX indicator (0.82%). However the purpose was to improve the methodology of how the ODEX was being calculated, not necessarily increasing the savings

Using photography to enhance GP trainees’ reflective practice and professional development.

The capacity and the commitment to reflect are integral to the practice of medicine and are core components of most GP training programmes. Teaching through the Humanities is a growing area within medical education, but one which is often considered a voluntary ‘add on’ for the interested doctor. This article describes an evaluation of a highly innovative pedagogical project which used photography as a means to enhance GP trainees’ reflective capacity, self awareness and professional development. Photography was used as a tool to develop GP trainees’ skills in recognising and articulating the attitudes, feelings and values that might impact on their clinical work and to enhance their confidence in their ability to deal with these concerns/issues. We submit that photography is uniquely well suited for facilitating insight and self-reflection because it provides the ability to record ‘at the touch of a button’ those scenes and images to which our attention is intuitively drawn without the need for – or the interference of – conscious decisions. This allows us the opportunity to reflect later on the reasons for our intuitive attraction to these scenes. These photography workshops were a compulsory part of the GP training programme and, despite the participants’ traditional scientific backgrounds, the results clearly demonstrate the willingness of participants to accept – even embrace – the use of Art as a tool for learning. The GP trainees who took part in this project acknowledged it to be beneficial for both their personal and professional development

Staged and non staged anaerobic filters : microbial selection, hydrodynamic aspects and performance

This work reports on the study of a staged and a non staged anaerobic filter treating a synthetic dairy waste under similar operating conditions. The effect of increasing the substrate concentration from 3 to 12 g COD/l at a constant hydraulic residence time (HRT) of 2 days was evaluated with respect to overall reactor performance, gas production and volatile fatty acids profiles along the height. The potential maximum specific methanogenic activity against acetate, H2/CO2, two indirect substrates (propionate and butyrate) and the lactose specific activity were determined for sludge sampled from three different points in each reactor, under two operating conditions (influent COD of 3 and 9 g COD/l). Although all microbial phases of anaerobic process were found throughout the reactors, it was possible to identify different specific sludges at different heights in both reactors. The pressure transducer technique applied was proven to be a reliable method to study methanogenic activity of different trophic groups in consortia. Performances of the two configurations were very similar under the operating conditions tested and the plug flow behaviour of the staged reactor was clearly reduced when the influent concentration increased from 3 to 9 g COD/l

Comparison of two configurations of upflow anaerobic filters : specific methanogenic activity profiles

The aim of this work was to determine the distribution of microbial activity along the height of two configurations of anaerobic filters treating a synthetic dairy waste. A traditional configuration was compared with a staged system which had biogas removal from each of the three stages. The effect of increasing the substrate concentration from 3 to 12 g COD/l at constant hydraulic residence time (HRT) of 2 days was evaluated with respect to overall reactor performance, gas production and effluent volatile fatty acids profiles. The potential maximum specific methanogenic activity against acetate, H2/CO2 and an indirect substrate (propionate) was determined for sludge sampled from three different points in each reactor, under two operating conditions (influent COD of 3 and 9 g COD/l). The increase in influent concentration was shown to promote a stratification of the specific acetoclastic activity more pronounced in the staged reactor. Both the hydrogenophilic and acetoclastic activities were highest at the top of the filters, whereas the methanogenic activity against propionate was maximum in the middle section and was very similar for both reactor configurations. The results confirmed the reliability of the pressure transducer technique to study methanogenic activity of different trophic groups in consortia