- Email: [email protected]
297 Central Venous Catheter Insertion Training: A Hospital-Wide Approach
Research Forum Abstracts simulation 88% vs 67% of BA; CL verbal 62% vs 44% of BA; LP simulation 100% vs 67% of BA; verbal 100% vs 80% of BA). Conclusion: Our data suggest that a simulation-based assessment technique may provide a more robust assessment of ongoing physician competence in medical procedures than verbal assessment. Additionally, above average checklist performance appears to correlate with higher expert rater confidence regarding physician proficiency. Using a simulated setting for assessment may provide a better assessment of physician proficiency in the same environment where remedial training may be immediately provided.
294
Thematic Analysis of Debrief Themes Emerging from High Fidelity Interprofessional In Situ Simulations in the Emergency Department
McFetridge C, Mastoras G, Poulin C, Norman L, Pozgay A, Weitzman B, Frank JR/ University of Ottawa, Ottawa, ON, Canada
Study Objectives: Resuscitation of critically ill patients is a cornerstone of emergency medicine, where outcomes are highly dependent on the complex interplay between effective teamwork, equipment and resource management and medical expertise. However, deficiencies in this process inevitably arise that negatively impact patient care. In situ simulation training has been gaining ground as an effective tool to improve emergency medical team performance. This ongoing prospective observational study involves the delivery of monthly, in situ simulations (SIM) followed by debrief sessions in two tertiary care emergency departments. This qualitative study sought to identify naturally emerging debrief themes that arose during interprofessional debrief sessions following in-situ simulations. Methods: Monthly, in situ simulation (SIM) sessions were conducted in the emergency departments of two tertiary care, academic hospitals. Sessions were composed of 2-3 high fidelity cases including management of sepsis, acute GI bleeds, cardiac arrest, pediatric resuscitation and trauma. Participants were recruited from the interprofessional team “on shift” in the ED and included attending emergency physicians, residents, nurses, respiratory therapists and other support staff. Simulation sessions were followed by a 20-minute, open format debrief facilitated by SIM trained emergency medicine faculty, residents and a nurse educator. Debriefers utilized generally techniques such as advocacy-inquiry and open-ended questioning to facilitate a free-flowing discussion on topics raised by the interprofessional team. Observational debrief data was collected by an experienced simulation nurse-research assistant from 11 SIM sessions, involving 30 cases and 181 participants. Results: Thematic analysis was performed on debrief data compiled by the research nurse. Debrief topics (134) were grouped into 7 broad themes: equipment/resources, situational awareness, communication, leadership, medical expertise, technical/ procedural skills and SIM factors. Frequencies were calculated with communication (42.5%), situational awareness (20.9%) and leadership (11.2%) emerging as the themes most commonly cited. Inherent SIM factors (10.4%) and equipment/resources (9.7%) were also somewhat common. Interestingly, medical expertise (3%) and technical/procedural skills (2.2%) were seldom mentioned. Further sub-thematic analysis uncovered the use of closed-loop communication (7.5%) and summaries from the team leader (7.5%) as the most frequent responses. Effective use of resources (5.2%), calling for help early (5.2%) and difficulty with suspension of reality during SIM (5.2%) were the next most frequently cited. Conclusion: Careful thematic, and sub-thematic analysis of common themes arising during interprofessional debriefing of in-situ simulation sessions identified areas of high concern among the ED critical care team - chiefly the importance of effective non-technical and teamwork skills. These data provide important direction for targeted, departmental quality improvement efforts and have the potential to positively impact overall patient care.
295
Provider BMI Significantly Impacts CPR Depth
Julie I, Al-Jahany M, Al-Khulaif A, Clarke S, Bair A/UC Davis Medical Center, Sacramento, CA; UC Davis, Sacramento, CA
Study Objectives: Depth of chest compressions is closely correlated with improved outcomes in cardiac arrest, but not all providers may deliver adequate chest compression depth.
Volume 68, no. 4s : October 2016
The objective of this study was to determine the experiential and biometric characteristics associated with adequate chest compression depth delivered by resident physicians. Methods: The study was a single-center descriptive study of the depth of chest compressions delivered by internal medicine residents. Each resident underwent a 1-hour training session focused on code management including specific hands-on training on effective chest compressions. Upon completion of the session residents were invited to perform 2 minutes of CPR on a Laerdal 3G SimMan under optimal conditions (performer rested, head of bed lowered, bed to lowest height, side rails down, backboard in place). Residents were then asked to provide information about their height and weight (used to calculate a Body Mass Index (BMI)), age, and prior experience delivering compressions. A total of 33 residents were included in final analysis. Adequate compression depth was defined as 35 mm and measured at 30-second intervals by the Laerdal model. Logistic regression models were derived to determine the independent contribution of BMI on compression depth. Results: Participants’ BMIs ranged from 17.75 to 40.68 and compression depth ranged from 24 to 59 mm. Wilcoxon rank sum tests demonstrate that BMI is a significant predictor of inadequate compression depth at 60, 90 and 120 seconds (Z ¼ -3.4, -3.3, -2.8 with p ¼ 0.001, 0.009, and 0.005, respectively). At 120 seconds, increased BMI was a significant associated with adequate compression depth (Odds Ratio¼ 1.2,95% CI 1.01-1.55). At 120 seconds, 15 residents performed adequate compressions with a mean BMI of 25.4 and 18 performed inadequate compressions with a mean BMI of 21.4. Conclusion: Providers with lower BMI are at higher risk of providing inadequate chest compression depth for greater than one minute. It may be beneficial for team members with higher BMI to deliver compressions during CPR.
296
Implementation of Tactical Breathing During Simulated Stressful Situations and Effects on Clinical Performance
Grubish L, Kessler J, McGrane K, Bothwell J/Madigan Army Medical Center, Tacoma, WA
Study Objectives: There is little research on stress and how it effects clinician performance. Mitigating stress has been shown to improve performance in clinical situations. Airway management is one of the stressful situations that emergency department physicians often find themselves in. Tactical breathing is a technique that has promise decreasing stress while maintaining optimal performance. Our study evaluates airway management in cadaveric model while undergoing simulated stressful situations while using tactical breathing. Methods: A prospective crossover design using a single cohort of emergency medicine residents was used for this study. The primary objective was to compare time to intubation in a simulated stressful situation with and without tactical breathing. The secondary objectives were measuring success rates of intubation and if participates would implement tactical breathing. Results: Mean time to intubation in the control group was 23.75 seconds while the mean time to intubation in a simulated stressful situation without tactical breathing was 24.90 seconds and with tactical breathing was 25.27 seconds. The overall success rate in the control group was 96%. The success rate in the simulated stressful situation without tactical breathing was 85% compared to the simulated stressful situation, which was 100%. When surveyed, 63% of the partipates strongly agreed/agreed that tactical breathing improved their performance where 15% where neutral or 22% disagreed. Conclusion: Although the mean intubation times between the groups were not significantly different, the overall success rate of intubation in the simulated stressful situation with tactical breathing was 100% with the majority of partipates agreeing that tactical breathing improved their success rate.
297
Central Venous Catheter Insertion Training: A Hospital-Wide Approach
Steiner B, Evans L, Bonz J/Yale New Haven Hospital, New Haven, CT; Yale-New Haven Hospital, New Haven, CT
Study Objectives: Procedural simulation increases operator efficiency and reduces complications. The evidence for this has been mounting over the last
Annals of Emergency Medicine S115
Research Forum Abstracts decade, and is well-established for the placement of central venous catheters (CVCs). Many specialties that routinely place CVCs have instituted their own simulation training courses for their trainees. These courses vary widely in rigor and content. In one hospital system there may be over five different simulation courses for training house staff. Many programs do not even have a formal training program in CVC placement. In the winter of 2015, the Director of Procedural Simulation at the Yale Center for Medical Simulation (YCMS) met with hospital administration of the Yale Health System to discuss the feasibility of a new concept: a hospitalmandated CVC training program that was a prerequisite to placing a CVC within the Yale Health System, regardless of specialty. This discussion was fostered by a desire on the part of hospital administration to address the ever-present morbidity associated with Central Line Associated Blood Stream Infections (CLABSI) and the higher than average rate of CVC associated pneumothoraxes within the health system. Once the hospital committed to a hospital-wide mandate, YCMS was chosen to direct the effort. In part, this was because YCMS has expertise in CVC training, having designed a CVC training course validated in an Agency for Healthcare Research and Quality (AHRQ) funded study. Methods: The first session starts with a small group discussion reviewing informed consent, CLABSI, CVC relevant anatomy, ultrasound and vascular access, as well as Seldinger technique. Next, the trainees undergo hands-on training with ultrasound and vascular access models. Lastly, the instructor leads an interactive demonstration of CVC placement while modeling complete sterile precautions throughout. The instructor highlights technical nuances and common pitfalls. The second session consists of one-on-one instruction with the trainee until they are ready to “test out.” The testing is done against a previously published predetermined checklist coupled with an evaluator driven global assessment to establish passing. The entire testing encounter is videotaped from two cameras and subsequently archived. Results: 102 residents from 14 specialties went through the mandated CVC training course. A total of 11 instructors taught a total of 129 hours. Ten trainees failed on their first attempt and required further training (10% failure rate). Of those who failed their first test, two failed a subsequent test (20%). Anonymous pre- and post-course surveys showed that trainees’ confidence level increased from 2.4 to 4.3 on a five point Likert scale. The total cost of administering this program was $30,938. Conclusions: The YCMS is in its first year of operating a mandatory hospital-wide CVC training program and will continue training all new house staff, fellows, and attendings in this important procedure. We believe that with mounting scholarship as its foundation, this type of mandate is necessary for improved patient care and that other institutions can gain from our experiences in implementing simulated procedural training as policy.
298
Detecting Blood Loss With a Wearable Photoplethysmography Device
Darling CE, Reljin N, Zimmer G, Malyuta Y, Blehar D, Mendelson Y, Chon K/UMass Medical School, Worcester, MA; University of Connecticut, Storrs, CT; Worcester Polytechnical Institute, Worcester, MA
Study Objective: Assessing trauma patients for occult hemorrhage is central to trauma triage. Massive bleeding (> 30% of blood volume), if not promptly treated, may progress to hemorrhagic shock. Identifying patients at risk of imminent shock is a challenging task in out-of-hospital and battlefield settings given the variability of traditional vital signs, such as pulse and blood pressure. In this investigation we describe the ability of wearable, photoplethysmography (PPG) devices to detect blood loss. Methods: Two groups of research subjects (n¼23) were analyzed. Group 1: 9 consenting volunteers subjected to 900 ml of bloodletting while wearing one or more PPG sensors, resulting in 19 recordings. Group 2: 14 emergency department (ED) patients consented to wear custom-made multichannel pulse oximeters on the same locations (forehead, ear and finger) (19 recordings as well), while experiencing no net blood loss as verified by blinded physician adjudication. PPG data was stored internally in the device and later analyzed. A machine learning algorithm was used to classify the two research groups and
S116 Annals of Emergency Medicine
the performance of the algorithm was measured by calculating sensitivity/ specificity. Results: The average age of research subjects was 34, 82% were male, initial sBP averaged 130 mmHg and HR 81 bpm. The analyzed PPG data demonstrated an overall accuracy of 82.9%, a sensitivity of 89.3% and a specificity of 78.2%. Conclusion: The preliminary results from this ongoing study of a novel, wearable PPG device demonstrate high sensitivity and moderate specificity at categorizing blood loss. Increasing the number of subjects, both with and without blood loss, will allow for a more thorough evaluation of the device’s capabilities.
299 300
Withdrawn
Comparative Analysis of Five Methods of Emergency Zipper Release by Experienced Versus Novice Clinicians
Oquist M, Buck L, Keegan M, Emery M, Bush C, Ouellette L/College of Human Medicine, Michigan State University, Grand Rapids, MI
Study Objective: Penile zipper injury is usually caused by entrapment of penile tissue (foreskin, shaft, or glans) in the actuator or the teeth of the zipper. It is one of the most common genital injuries in prepubertal boys. The primary aim of this proposal was to compare five common techniques for releasing zipper-entrapped skin using an animal model. Methods: This was a prospective, randomized trial using an animal model consisting of chicken skin firmly entrapped by a metal zipper on a pair of denim jeans. Volunteers consisted of emergency medicine physician faculty and medical students (novice clinicians). During the simulation lab, participants were taught the five common techniques for releasing zipper-entrapped skin: 1) cutting the median bar; 2) using a screwdriver to separate faceplates; 3) manipulation of the zipper using mineral oil; 4) lateral compression of the zip fastener using pliers; and 5) removing the teeth of zip mechanism using trauma scissors. Order of the techniques was chosen by a random number generator. Subjects were timed by evaluators using a digital stopwatch from the time they were told to start until successful release of the entrapped skin. Success was defined as release of the entrapped skin while minimizing trauma to the skin. Failure to successfully release the entrapped skin within 5 minutes or causing full thickness laceration to the skin was logged as failures. Comparisons were made between each technique and between training levels (ie, student versus faculty) for both success rate and time to successful release of entrapped skin utilizing Chi-Square, and 2-tailed unpaired ttests. Results: Volunteers consisted of 12 EM physician faculty and 18 medical students. Overall, procedure times were 16.2 sec faster for EM faculty compared to students (P<.05); however, success rates did not vary significantly. Gentle manipulation of the zipper using mineral oil lubricant was clearly the most successful technique in novice (94%) or experienced clinicians (100%). Because of the small number of successful procedures, the times in student and faculty clinicians were combined. Gentle manipulation of the zipper using mineral oil lubricant was the quickest technique among novice or experienced clinicians (53.9 +/- 25.6 sec), followed by cutting the median bar (126.0 +/- 110 sec) and use of a screwdriver to widen the faceplates (131.6 +/- 90.5 sec). The procedure that was the least traumatic to skin involved cutting the closed teeth of the zipper using trauma scissors, permitting the unzipping of the zipper from the distal end (P<.05). Using this method there is no direct manipulation of the entrapped skin, minimizing skin trauma. Gentle manipulation was the preferred technique overall, followed by cutting the closed teeth of the zipper using trauma scissors, permitting the unzipping of the zipper from the distal end. Conclusions: This is the first randomized trial to compare the five methods for releasing zipper-entrapped skin. Based on our animal model the preferred technique is simply gentle manipulation of the zipper using mineral oil lubricant. If this is not immediately effective, clinicians may wish to try cutting the closed teeth of the zipper using trauma scissors, and unzipping the zipper from the distal end.
Volume 68, no. 4s : October 2016
294
Thematic Analysis of Debrief Themes Emerging from High Fidelity Interprofessional In Situ Simulations in the Emergency Department
McFetridge C, Mastoras G, Poulin C, Norman L, Pozgay A, Weitzman B, Frank JR/ University of Ottawa, Ottawa, ON, Canada
Study Objectives: Resuscitation of critically ill patients is a cornerstone of emergency medicine, where outcomes are highly dependent on the complex interplay between effective teamwork, equipment and resource management and medical expertise. However, deficiencies in this process inevitably arise that negatively impact patient care. In situ simulation training has been gaining ground as an effective tool to improve emergency medical team performance. This ongoing prospective observational study involves the delivery of monthly, in situ simulations (SIM) followed by debrief sessions in two tertiary care emergency departments. This qualitative study sought to identify naturally emerging debrief themes that arose during interprofessional debrief sessions following in-situ simulations. Methods: Monthly, in situ simulation (SIM) sessions were conducted in the emergency departments of two tertiary care, academic hospitals. Sessions were composed of 2-3 high fidelity cases including management of sepsis, acute GI bleeds, cardiac arrest, pediatric resuscitation and trauma. Participants were recruited from the interprofessional team “on shift” in the ED and included attending emergency physicians, residents, nurses, respiratory therapists and other support staff. Simulation sessions were followed by a 20-minute, open format debrief facilitated by SIM trained emergency medicine faculty, residents and a nurse educator. Debriefers utilized generally techniques such as advocacy-inquiry and open-ended questioning to facilitate a free-flowing discussion on topics raised by the interprofessional team. Observational debrief data was collected by an experienced simulation nurse-research assistant from 11 SIM sessions, involving 30 cases and 181 participants. Results: Thematic analysis was performed on debrief data compiled by the research nurse. Debrief topics (134) were grouped into 7 broad themes: equipment/resources, situational awareness, communication, leadership, medical expertise, technical/ procedural skills and SIM factors. Frequencies were calculated with communication (42.5%), situational awareness (20.9%) and leadership (11.2%) emerging as the themes most commonly cited. Inherent SIM factors (10.4%) and equipment/resources (9.7%) were also somewhat common. Interestingly, medical expertise (3%) and technical/procedural skills (2.2%) were seldom mentioned. Further sub-thematic analysis uncovered the use of closed-loop communication (7.5%) and summaries from the team leader (7.5%) as the most frequent responses. Effective use of resources (5.2%), calling for help early (5.2%) and difficulty with suspension of reality during SIM (5.2%) were the next most frequently cited. Conclusion: Careful thematic, and sub-thematic analysis of common themes arising during interprofessional debriefing of in-situ simulation sessions identified areas of high concern among the ED critical care team - chiefly the importance of effective non-technical and teamwork skills. These data provide important direction for targeted, departmental quality improvement efforts and have the potential to positively impact overall patient care.
295
Provider BMI Significantly Impacts CPR Depth
Julie I, Al-Jahany M, Al-Khulaif A, Clarke S, Bair A/UC Davis Medical Center, Sacramento, CA; UC Davis, Sacramento, CA
Study Objectives: Depth of chest compressions is closely correlated with improved outcomes in cardiac arrest, but not all providers may deliver adequate chest compression depth.
Volume 68, no. 4s : October 2016
The objective of this study was to determine the experiential and biometric characteristics associated with adequate chest compression depth delivered by resident physicians. Methods: The study was a single-center descriptive study of the depth of chest compressions delivered by internal medicine residents. Each resident underwent a 1-hour training session focused on code management including specific hands-on training on effective chest compressions. Upon completion of the session residents were invited to perform 2 minutes of CPR on a Laerdal 3G SimMan under optimal conditions (performer rested, head of bed lowered, bed to lowest height, side rails down, backboard in place). Residents were then asked to provide information about their height and weight (used to calculate a Body Mass Index (BMI)), age, and prior experience delivering compressions. A total of 33 residents were included in final analysis. Adequate compression depth was defined as 35 mm and measured at 30-second intervals by the Laerdal model. Logistic regression models were derived to determine the independent contribution of BMI on compression depth. Results: Participants’ BMIs ranged from 17.75 to 40.68 and compression depth ranged from 24 to 59 mm. Wilcoxon rank sum tests demonstrate that BMI is a significant predictor of inadequate compression depth at 60, 90 and 120 seconds (Z ¼ -3.4, -3.3, -2.8 with p ¼ 0.001, 0.009, and 0.005, respectively). At 120 seconds, increased BMI was a significant associated with adequate compression depth (Odds Ratio¼ 1.2,95% CI 1.01-1.55). At 120 seconds, 15 residents performed adequate compressions with a mean BMI of 25.4 and 18 performed inadequate compressions with a mean BMI of 21.4. Conclusion: Providers with lower BMI are at higher risk of providing inadequate chest compression depth for greater than one minute. It may be beneficial for team members with higher BMI to deliver compressions during CPR.
296
Implementation of Tactical Breathing During Simulated Stressful Situations and Effects on Clinical Performance
Grubish L, Kessler J, McGrane K, Bothwell J/Madigan Army Medical Center, Tacoma, WA
Study Objectives: There is little research on stress and how it effects clinician performance. Mitigating stress has been shown to improve performance in clinical situations. Airway management is one of the stressful situations that emergency department physicians often find themselves in. Tactical breathing is a technique that has promise decreasing stress while maintaining optimal performance. Our study evaluates airway management in cadaveric model while undergoing simulated stressful situations while using tactical breathing. Methods: A prospective crossover design using a single cohort of emergency medicine residents was used for this study. The primary objective was to compare time to intubation in a simulated stressful situation with and without tactical breathing. The secondary objectives were measuring success rates of intubation and if participates would implement tactical breathing. Results: Mean time to intubation in the control group was 23.75 seconds while the mean time to intubation in a simulated stressful situation without tactical breathing was 24.90 seconds and with tactical breathing was 25.27 seconds. The overall success rate in the control group was 96%. The success rate in the simulated stressful situation without tactical breathing was 85% compared to the simulated stressful situation, which was 100%. When surveyed, 63% of the partipates strongly agreed/agreed that tactical breathing improved their performance where 15% where neutral or 22% disagreed. Conclusion: Although the mean intubation times between the groups were not significantly different, the overall success rate of intubation in the simulated stressful situation with tactical breathing was 100% with the majority of partipates agreeing that tactical breathing improved their success rate.
297
Central Venous Catheter Insertion Training: A Hospital-Wide Approach
Steiner B, Evans L, Bonz J/Yale New Haven Hospital, New Haven, CT; Yale-New Haven Hospital, New Haven, CT
Study Objectives: Procedural simulation increases operator efficiency and reduces complications. The evidence for this has been mounting over the last
Annals of Emergency Medicine S115
Research Forum Abstracts decade, and is well-established for the placement of central venous catheters (CVCs). Many specialties that routinely place CVCs have instituted their own simulation training courses for their trainees. These courses vary widely in rigor and content. In one hospital system there may be over five different simulation courses for training house staff. Many programs do not even have a formal training program in CVC placement. In the winter of 2015, the Director of Procedural Simulation at the Yale Center for Medical Simulation (YCMS) met with hospital administration of the Yale Health System to discuss the feasibility of a new concept: a hospitalmandated CVC training program that was a prerequisite to placing a CVC within the Yale Health System, regardless of specialty. This discussion was fostered by a desire on the part of hospital administration to address the ever-present morbidity associated with Central Line Associated Blood Stream Infections (CLABSI) and the higher than average rate of CVC associated pneumothoraxes within the health system. Once the hospital committed to a hospital-wide mandate, YCMS was chosen to direct the effort. In part, this was because YCMS has expertise in CVC training, having designed a CVC training course validated in an Agency for Healthcare Research and Quality (AHRQ) funded study. Methods: The first session starts with a small group discussion reviewing informed consent, CLABSI, CVC relevant anatomy, ultrasound and vascular access, as well as Seldinger technique. Next, the trainees undergo hands-on training with ultrasound and vascular access models. Lastly, the instructor leads an interactive demonstration of CVC placement while modeling complete sterile precautions throughout. The instructor highlights technical nuances and common pitfalls. The second session consists of one-on-one instruction with the trainee until they are ready to “test out.” The testing is done against a previously published predetermined checklist coupled with an evaluator driven global assessment to establish passing. The entire testing encounter is videotaped from two cameras and subsequently archived. Results: 102 residents from 14 specialties went through the mandated CVC training course. A total of 11 instructors taught a total of 129 hours. Ten trainees failed on their first attempt and required further training (10% failure rate). Of those who failed their first test, two failed a subsequent test (20%). Anonymous pre- and post-course surveys showed that trainees’ confidence level increased from 2.4 to 4.3 on a five point Likert scale. The total cost of administering this program was $30,938. Conclusions: The YCMS is in its first year of operating a mandatory hospital-wide CVC training program and will continue training all new house staff, fellows, and attendings in this important procedure. We believe that with mounting scholarship as its foundation, this type of mandate is necessary for improved patient care and that other institutions can gain from our experiences in implementing simulated procedural training as policy.
298
Detecting Blood Loss With a Wearable Photoplethysmography Device
Darling CE, Reljin N, Zimmer G, Malyuta Y, Blehar D, Mendelson Y, Chon K/UMass Medical School, Worcester, MA; University of Connecticut, Storrs, CT; Worcester Polytechnical Institute, Worcester, MA
Study Objective: Assessing trauma patients for occult hemorrhage is central to trauma triage. Massive bleeding (> 30% of blood volume), if not promptly treated, may progress to hemorrhagic shock. Identifying patients at risk of imminent shock is a challenging task in out-of-hospital and battlefield settings given the variability of traditional vital signs, such as pulse and blood pressure. In this investigation we describe the ability of wearable, photoplethysmography (PPG) devices to detect blood loss. Methods: Two groups of research subjects (n¼23) were analyzed. Group 1: 9 consenting volunteers subjected to 900 ml of bloodletting while wearing one or more PPG sensors, resulting in 19 recordings. Group 2: 14 emergency department (ED) patients consented to wear custom-made multichannel pulse oximeters on the same locations (forehead, ear and finger) (19 recordings as well), while experiencing no net blood loss as verified by blinded physician adjudication. PPG data was stored internally in the device and later analyzed. A machine learning algorithm was used to classify the two research groups and
S116 Annals of Emergency Medicine
the performance of the algorithm was measured by calculating sensitivity/ specificity. Results: The average age of research subjects was 34, 82% were male, initial sBP averaged 130 mmHg and HR 81 bpm. The analyzed PPG data demonstrated an overall accuracy of 82.9%, a sensitivity of 89.3% and a specificity of 78.2%. Conclusion: The preliminary results from this ongoing study of a novel, wearable PPG device demonstrate high sensitivity and moderate specificity at categorizing blood loss. Increasing the number of subjects, both with and without blood loss, will allow for a more thorough evaluation of the device’s capabilities.
299 300
Withdrawn
Comparative Analysis of Five Methods of Emergency Zipper Release by Experienced Versus Novice Clinicians
Oquist M, Buck L, Keegan M, Emery M, Bush C, Ouellette L/College of Human Medicine, Michigan State University, Grand Rapids, MI
Study Objective: Penile zipper injury is usually caused by entrapment of penile tissue (foreskin, shaft, or glans) in the actuator or the teeth of the zipper. It is one of the most common genital injuries in prepubertal boys. The primary aim of this proposal was to compare five common techniques for releasing zipper-entrapped skin using an animal model. Methods: This was a prospective, randomized trial using an animal model consisting of chicken skin firmly entrapped by a metal zipper on a pair of denim jeans. Volunteers consisted of emergency medicine physician faculty and medical students (novice clinicians). During the simulation lab, participants were taught the five common techniques for releasing zipper-entrapped skin: 1) cutting the median bar; 2) using a screwdriver to separate faceplates; 3) manipulation of the zipper using mineral oil; 4) lateral compression of the zip fastener using pliers; and 5) removing the teeth of zip mechanism using trauma scissors. Order of the techniques was chosen by a random number generator. Subjects were timed by evaluators using a digital stopwatch from the time they were told to start until successful release of the entrapped skin. Success was defined as release of the entrapped skin while minimizing trauma to the skin. Failure to successfully release the entrapped skin within 5 minutes or causing full thickness laceration to the skin was logged as failures. Comparisons were made between each technique and between training levels (ie, student versus faculty) for both success rate and time to successful release of entrapped skin utilizing Chi-Square, and 2-tailed unpaired ttests. Results: Volunteers consisted of 12 EM physician faculty and 18 medical students. Overall, procedure times were 16.2 sec faster for EM faculty compared to students (P<.05); however, success rates did not vary significantly. Gentle manipulation of the zipper using mineral oil lubricant was clearly the most successful technique in novice (94%) or experienced clinicians (100%). Because of the small number of successful procedures, the times in student and faculty clinicians were combined. Gentle manipulation of the zipper using mineral oil lubricant was the quickest technique among novice or experienced clinicians (53.9 +/- 25.6 sec), followed by cutting the median bar (126.0 +/- 110 sec) and use of a screwdriver to widen the faceplates (131.6 +/- 90.5 sec). The procedure that was the least traumatic to skin involved cutting the closed teeth of the zipper using trauma scissors, permitting the unzipping of the zipper from the distal end (P<.05). Using this method there is no direct manipulation of the entrapped skin, minimizing skin trauma. Gentle manipulation was the preferred technique overall, followed by cutting the closed teeth of the zipper using trauma scissors, permitting the unzipping of the zipper from the distal end. Conclusions: This is the first randomized trial to compare the five methods for releasing zipper-entrapped skin. Based on our animal model the preferred technique is simply gentle manipulation of the zipper using mineral oil lubricant. If this is not immediately effective, clinicians may wish to try cutting the closed teeth of the zipper using trauma scissors, and unzipping the zipper from the distal end.
Volume 68, no. 4s : October 2016