Importance of debriefing in high-fidelity simulations

Vodena razprava (angl. debriefing) je najpomembnejši del učenja s simulacijami visoke stopnje posnemanja resničnosti, v kateri mentor pozove učeče se, da kritično ocenijo znanje in spretnosti, ki so jih pokazali med izvedbo scenarija. Kljub številnim raziskavam, ki proučujejo izobraževanje s simulacijami, je področje vodene razprave še razmeroma slabo opredeljeno. V prispevku so o sodobni literaturi povzete bistvene značilnosti vodene razprave, njene faze, tehnike in metode. Poudarjena je vloga mentorja, saj je učinkovitost vodene razrave v veliki meri odvisna ravno od njegove usposobljenosti. Podane so smernice, s katerimi mentor lahko oceni lastno uspešnost pri vodenju razprave. Prav tako je izpostavljen pomen pri kontinuiranem izobraževanju v kliničnem okolju, saj vodena razprava omogoča oceno uspešnosti izvedbe klinične obravnave in možnosti postavljanja novih strategij s ciljem doseči večjo usposobljenost zdravstvenega tima. Čeprav je vodena razprava temelj izobraževanja s simulacijami visoke stopnje posnemanja resničnosti, je tudi pomemben način učenja v kliničnem okolju. Mnogi vidiki vodene razprave so še vedno slabo raziskani, zato bo temu segmentu v prihodnosti potrebno nameniti večjo pozornost

The dynamic pattern of end-tidal carbon dioxide during cardiopulmonary resuscitation: difference between asphyxial cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest

Introduction: Partial pressure of end-tidal carbon dioxide (PetCO2) during cardiopulmonary resuscitation (CPR) correlates with cardiac output and consequently has a prognostic value in CPR. In our previous study we confirmed that initial PetCO2 value was significantly higher in asphyxial arrest than in ventricular fibrillation/pulseless ventricular tachycardia (VF/VT) cardiac arrest. In this study we sought to evaluate the pattern of PetCO2 changes in cardiac arrest caused by VF/VT and asphyxial cardiac arrest in patients who were resuscitated according to new 2005 Guidelines. Methods: The study included two cohorts of patients: cardiac arrest due to asphyxia with initial rhythm asystole or pulseless electrical activity (PEA), and cardiac arrest due to arrhythmia with initial rhythm VF or pulseless VT. PetCO2 was measured for both groups immediately after intubation and repeatedly every minute, both for patients with or without return of spontaneous circulation (ROSC). We compared the dynamic pattern of PetCO2 between groups. Results: Between June 2006 and June 2009 resuscitation was attempted in 325 patients and in this study we included 51 patients with asphyxial cardiac arrest and 63 patients with VF/VT cardiac arrest. The initial values of PetCO2 were significantly higher in the group with asphyxial cardiac arrest (6.74 +/- 4.22 kPa versus 4.51 +/- 2.47 kPaP = 0.004). In the group with asphyxial cardiac arrest, the initial values of PetCO2 did not show a significant difference when we compared patients with and without ROSC (6.96 +/- 3.63 kPa versus 5.77 +/- 4.64 kPaP = 0.313). We confirmed significantly higher initial PetCO2 values for those with ROSC in the group with primary cardiac arrest (4.62 +/- 2.46 kPa versus 3.29 +/- 1.76 kPaP = 0.041). A significant difference in PetCO2 values for those with and without ROSC was achieved after five minutes of CPR in both groups. In all patients with ROSC the initial PetCO2 was again higher than 1.33 kPa. Conclusions: The dynamic pattern of PetCO2 values during out-of-hospital CPR showed higher values of PetCO2 in the first two minutes of CPR in asphyxia, and a prognostic value of initial PetCO2 only in primary VF/VT cardiac arrest. A prognostic value of PetCO2 for ROSC was achieved after the fifth minute of CPR in both groups and remained present until final values. This difference seems to be a useful criterion in prehospital diagnostic procedures and attendance of cardiac arrest

Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study

Introduction: The prognosis among patients who suffer out-of-hospital cardiac arrest is poor. Higher survival rates have been observed only in patients with ventricular fibrillation who were fortunate enough to have basic and advanced life support initiated early after cardiac arrest. The ability to predict outcomes of cardiac arrest would be useful for resuscitation. Changes in expired end-tidal carbon dioxide levels during cardiopulmonary resuscitation may be a useful non-invasive predictor of successful resuscitation and survival from cardiac arrest, and help in the termination of cardiopulmonary resuscitation in the field. Methods: This is a prospective observational study of 737 cases of victims who suffered sudden out-of-hospital cardiac arrest. The patients were intubated and the measurements of end-tidal carbon dioxide were performed. Data according to the Utstein criteria, demographic information, medical data and partial pressure of end-tidal carbon dioxide (petCO2) values were collected for each patient in cardiac arrest, by the emergency physician. We presumed that an end-tidal carbon dioxide level of 1.9 kPa (14.3 mmHg) or more after 20 minutes of standard advanced cardiac life support would predict restoration of spontaneous circulation (ROSC). Results: Partial pressure of end-tidal carbon dioxide after 20 minutes of advanced life support averaged 0.92+/- 0.29 kPa (6.9mmHg +/- 2.2 mmHg) in patients who did not have ROSC and 4.36 +/-1.11 kPa (32.8 mmHg +/- 9.1 mmHg) in those who did (p<0,001). End-tidal carbon dioxide values of 1.9 kPa (14.3 mmHg) or less discriminated between the 402 patients with ROSC and 335 patients without ROSC. When a 20-minute end-tidal carbon dioxide value of 1.9 kPa (14.3 mmHg) or less was used as a screening test to predict ROSC, the sensitivity, specificity, positive predictive value, and negative predictive value were all 100 percent. Conclusions: Measurements of end-tidal carbon dioxide levels of more than 1.9 kPa (14.3 mmHg) after 20 minutes should be used to accurately predict ROSC. End-tidal carbon dioxide levels should be monitored during cardiopulmonary resuscitation and considered a useful prognostic value for determining the outcome of resuscitative efforts and termination of cardio-pulmonary resuscitation in the field

Capnometry in suspected pulmonary embolism with positive D-dimer in the field

Introduction: Pulmonary embolism (PE) is one of the greatest diagnostic challenges in prehospital emergency setting. Most patients with suspected PE have a positive D-dimer and undergo diagnostic testing. Excluding PE with additional non-invasive tests would reduce the need for further imaging tests. We aimed to determine the effectiveness of combination of clinical probability and end-tidal carbon dioxide (PetCO2) for evaluation of suspected PE with abnormal concentrations of D-dimer in prehospital emergency setting. Methods: We assessed clinical probability of PE and PetCO2 measurement in 100 consecutive patients with suspected PE and positive D-dimer in the field. PetCO2 > 28 mmHg was considered as the best cut-off point. PE was excluded or confirmed by hospital physicians in the University Clinical Center Maribor by computer tomography (CT), ventilation/ perfusion scan echocardiography and pulmonary angiography. Results: PE was confirmed in 41 patients. PetCO2 had a sensitivity of 92.6% (95% CI, 79 to 98%), a negative predictive value of 94.2 % (95% CI, 83 to 99%), a specificity of 83 % (95% CI, 71 to 91%) and a positive predictive value of 79.2% (95% CI, 65 to 89%). Thirty-five patients (35%) had both a low (PE unlikely) clinical probability and a normal PetCO2 (sensitivity: 100%, 95% CI: 89 to 100%) and twenty-eight patients (28%) had both a high clinical probability (PE likely) and abnormal PetCO2 (specificity: 93.2%, 95% CI: 83 to 98%). Conclusions: The combination of clinical probability and PetCO2 may safely rule out PE in patients with suspected PE and positive D-dimer in the prehospital setting

Clinical and Demographic Characteristics of Patients with Molluscum Contagiosum Treated at the University Dermatology Clinic Maribor in a 5-year period

Molluscum contagiosum virus (MCV) is a common skin pathogen in both adults and children. In this prospective study, we clinically evaluated consecutive patients with molluscum contagiosum (MC) who had been examined during a 5-year period at the second-largest dermatology clinic in Slovenia and described their main demographic and clinical characteristics, concomitant diseases, and treatment success. The study included 188 patients, of which 121 (64%) were men and 67 (36%) were women. A total of 135 (72%) patients were adults, with lesions that were most commonly located in the anogenital region (98%) and were probably sexually acquired. Two adult patients were diagnosed with concurrent human immunodeficiency virus (HIV) infection. Fifty-three (28%) patients were children with a mean age of 5.7 years, most commonly presenting with lesions on the torso and extremities (85%). In adults, the infection most commonly occurred in male patients, while in children it was slightly more common in female patients. At presentation, 58% of patients had more than 5 MC lesions. A total of 30% of the included children had concomitant atopic dermatitis. We did not observe an increased occurrence of MCV infection in patients with atopic dermatitis. All patients were treated with curettage of the lesions. The cure rate at the first follow-up visit after 2 months was relatively high (63%), and recurrences were not associated with the number or site of lesions at presentation or with concomitant atopic dermatitis. </p

Sodelovanje med medicinskimi sestrami in zdravniki

Uvod: Dobro sodelovanje med zdravniki in medicinskimi sestrami omogoča višjo kakovost zdravstvene obravnave pacientov. Namen raziskave je bil ugotoviti, kako odnose med medicinskimi sestrami in zdravniki ocenjujejo študenti zdravstvene nege in medicine. Metode: V neeksperimentalni kvantitativni raziskavi je bila uporabljena Jeffersonova lestvica za oceno sodelovanja med zdravniki in medicinskimi sestrami. V priložnostni vzorec je bilo zajetih 428 študentov. Od tega 235 (54,9 %) študentov zdravstvene nege in 193 (45,1 %) študentov medicine. Podatki so bili analizirani z bivariatno statistiko in t-testom. Rezultati: Ugotovitve kažejo statistično pomembne razlike glede na spol anketirancev, pri nekaterih trditvah pa tudi glede na vrsto študija.  Anketiranke so se v večji meri strinjale s trditvami. Največja razlika glede na spol anketiranih je bila pri trditvi, da bi morali biti študentje medicine in zdravstvene nege vključeni v timsko delo, da bi razumeli svoje vloge (t = 2,59, p = 0,010). Študentje zdravstvene nege so se večinoma bolj strinjali s trditvami kot študentje medicine. V primerjavi med vrstama študija je bila največja razlika glede strinjanja pri trditvi »Na medicinsko sestro je treba gledati kot na zdravnikovo sodelavko in kolegico in ne kot na pomočnico« (t = 15,24, p < 0,001). Diskusija in zaključek: Ugotovitve kažejo statistično pomembne razlike v oceni odnosov med medicinskimi sestrami in zdravniki glede na spol anketiranih ter vrsto študija. Razlike glede različnih pogledov študentov obeh fakultet ponujajo priložnost za načrtovanje obeh izobraževanih programov

Risk factors for fatal outcome in patients with opioid dependence treated with methadone in a family medicine setting in Croatia

Aim To determine the risk factors for fatal outcome in patients with opioid dependence treated with methadone at the primary care level. Methods A group of 287 patients with opioid dependence was monitored prospectively from 1995 to 2007. At the beginning of the study, we collected the data on patient baseline characteristics, treatment characteristics, and living environment. At the annual check-up, we collected the data on daily methadone dose, method of methadone therapy administration, and family physician’s assessment of the patient’s drug use status. Results Out of 287 patients, 8% died. Logistic regression analysis showed that the predictors of fatal outcome were continuation of drug use during previous therapeutic attempts (odds ratio [OR], 19.402; 95% confidence interval [CI], 1.659-226.873), maintenance therapy as the planned treatment modality (OR, 3.738; 95% CI, 1.045-13.370), living in an unstable relationship (OR, 9.275; 95% CI, 2.207- 38.984), and loss of continuity of care (OR, 12.643; 95% CI, 3.001-53.253). Conclusion The patients presenting these risk factors require special attention. It is important for family physicians to insist on compliance with the treatment protocol and intervene when they lose contact with the patient to prevent the fatal outcome

Heuristic generation of medical simulation scenarios

Sodobno izobraževanje zdravstvenih delavcev zahteva uporabo medicinskih simulatorjev, saj medicina postaja zahtevna in kompleksna. Simulatorji potrebujejo scenarije, ki jih izdelujejo zdravniki, vendar je tak pristop subjektiven, ker ima vsak zdravnik svoje lastne izkušnje. Scenarije lahko izboljšamo z uporabo metod strojnega učenja. V doktorskem delu raziščemo in uporabimo Bayesove verjetnostne mreže kot računalniško podprto orodje za izdelavo scenarijev. Predstavimo metodologijo CasGEN, ki jo uporabimo na realnem primeru večje podatkovne zbirke s področja urgentne medicine - 737 primerov predbolnišničnega oživljanja. Rezultate validiramo s pomočjo trifaznega modela zastoja srca pri prekatni fibrilaciji. V doktorskem delu potrdimo ustreznost metodologije CASGen na podlagi študije, ki so jo pozitivno ocenili eksperti s področja medicine. Na tak način potrdimo hipotezo raziskovalnega dela, da je predstavljena metodologija CASGen uporabno orodje za generiranje medicinskih scenarijev.Modern education in health care today can not exist without the use medical simulators, which are state of the art for efficient learning. Simulators use scenarios, which are designed by physician’s own experiences and presents a subjective approach by scenario design. In doctoral thesis machine learning methods for building scenarios from real data are presented. In particularly we introduce Bayesian probability networks as the primary tool for scenario design. We present a methodology CASGen (Computer Aided Scenario Generation) which uses Bayesian network (BN) and apply it of real study of emergency medicine, where 737 cases in prehospital resuscitation were collected. The results of CASGen are validated with the three phase model for ventricular fibrillation. We confirm the hypothesis of the research that BN are appropriate method for supporting scenario design. The application and use of CASGen was independently confirmed by experts from medical domain