Biomedical subjects
Publications and source records attributed to Louis P Halamek.
Despite the large body of information regarding the beneficial effects of continuous positive airway pressure (CPAP) in infants with respiratory distress syndrome (RDS) data are insufficient at this time to support or refute its use during neonatal resuscitation. An individualized approach to infants with respiratory distress is recommended.
OBJECTIVE: The obstetric and neonatal exploratory focus group of the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative 2002 set out to improve collaboration, communication, and coordination between maternal and neonatal caregivers in 3 areas: the pregnancy at 22 to 26 weeks, measurement of maternal outcomes that are linked with neonatal outcomes, and team performance during high-risk delivery. Antepartum and intrapartum maternal attributes and interventions also were considered important measurements to identify practice variations and their relationship to neonatal outcomes for ongoing obstetric and neonatal collaboration. METHODS: Potentially better practices were developed on the basis of evidence in the literature, expert opinion, and internal analysis at the participating perinatal centers. The potentially better practices include development of local guidelines at each center for the care and counseling of pregnant women who are at risk for delivering at the margin of viability; communication strategies for obstetric and neonatology providers relating to high-risk pregnancy treatment plans; team communication and performance at high-risk deliveries; design of organizational structures and processes that facilitate obstetric and neonatal collaboration; and development of perinatal data to evaluate effects of perinatal practices on maternal, fetal, and neonatal outcomes. RESULTS: As a result of the project, participating centers developed local guidelines for pregnancies between 22 and 26 weeks, created a cross-center maternal database that currently is being linked to neonatal outcomes, and completed a pilot study on video simulation of neonatal-perinatal team communication. CONCLUSIONS: Increased understanding of practice variation in the management of care for infants who are at the margins of viability, locally developed guidelines, and a focus on improved team communication during delivery can be accomplished with a multicenter collaborative approach.
BACKGROUND: Access to resuscitation equipment is a critical component in delivering optimal care in pediatric arrest situations. Historically, children's hospitals and clinics have used a standard pediatric resuscitation cart ("standard cart") in which drawers are organized by intervention (eg, intubation module, intravenous module), requiring multiple drawers to be opened during a code. Many emergency departments, however, use a pediatric resuscitation cart based on the Broselow tape ("Broselow cart") in which each drawer is color coded and organized by patient length and weight ranges; each drawer contains all necessary equipment for resuscitation of a patient in that specific length/weight range. A literature review has revealed no studies examining the utility of either cart. OBJECTIVES: To compare which resuscitation cart organization (standard versus Broselow) allows for faster access to equipment, more accurate selection of appropriately sized equipment, and better user satisfaction. Methodology. We performed a prospective, randomized, controlled, crossover trial in which 21 pediatric health care providers were assigned the role of obtaining the appropriate equipment during 2 standardized, simulated codes alternately using either a standard or Broselow cart. Time to and accuracy of the selection of appropriate medical equipment along with posttesting satisfaction were measured. All simulations were performed in the Center for Advanced Pediatric Education at Stanford University Medical Center (Stanford, CA), a training facility designed to replicate the real medical environment with the technology to allow for videotaping of scenarios. RESULTS: Of the 21 subjects, 62% found the Broselow cart "easy" or "very easy" to use versus 33% for the standard cart. Of the 21 subjects, 67% preferred the Broselow cart, 10% preferred the standard cart, and 23% indicated no preference. Intubation supplies and nasogastric tubes were found significantly faster when using the Broselow cart (mean time: 29.1 and 20 seconds, respectively) versus the standard cart (mean time: 38.7 and 38.2 seconds, respectively). Correct equipment was provided a statistically significant 99% of the time with the Broselow cart versus 83% of the time with the standard cart. Ten percent of the subjects had prior experience with the Broselow cart versus 62% having experience with the standard cart. CONCLUSIONS: Despite less prior experience with the Broselow cart, subjects in this study found it easier to use and preferred it over the standard cart. In addition, subjects located intubation equipment and nasogastric tubes significantly faster when using the Broselow cart, and correct equipment was provided significantly more often with the Broselow cart. These data suggest that sites caring for pediatric patients should consider modeling their resuscitation carts after the Broselow cart to enhance provider confidence and patient safety.
Simulation-based training is a novel approach that facilitates the use of higher order thinking skills. Simulation-based training challenges medical professionals to develop cognitive, technical, and behavioral skills through the use of mannequins, working medical equipment, and human colleagues. During scenarios, trainees must make use of their knowledge base, analyze and synthesize factors contributing to the crises, and evaluate the effects of their actions. Feedback indicates that simulation-based training programs are more pertinent to and better accepted by adult learners than traditional programs. The instructional methodologies used in simulation-based training programs are more in line with the tenets of adult learning.
OBJECTIVE: To investigate current patterns of training and competency assessment in electronic fetal monitoring (EFM) for obstetrics and gynecology residents and maternal-fetal medicine fellows. METHODS: A questionnaire was mailed to the directors of all 254 accredited US residencies in obstetrics and gynecology and 61 accredited US fellowships in maternal-fetal medicine. Questions focused on the methods used for teaching and assessing competency in EFM. RESULTS: Two hundred thirty-nine programs (76%) responded to the survey. Clinical experience is used by 219 programs (92%) to teach EFM, both initially and on an ongoing basis. Significantly more residencies than fellowships use written materials and lectures to teach EFM. More than half of all programs require trainees to participate in some type of EFM training at least every 6 months; 23 programs (10%) have no requirement at all. Subjective evaluation is used by 174 programs (73%) to assess competency in EFM. Written or oral examinations, skills checklists, and logbooks are used exclusively by residencies as means of competency assessment. Two thirds of all programs assess EFM skills at least every 6 months; 40 programs (17%), the majority of which are fellowships, have no formal requirement. CONCLUSION: Most US training programs use supervised clinical experience as both their primary source of teaching EFM and their principal competency assessment tool. Residencies are more likely to have formal instruction and assessment than are fellowships. Few programs are using novel strategies (eg, computers or simulators) in their curriculum.
Extracorporeal membrane oxygenation (ECMO) therapy requires that patients be anticoagulated to prevent clotting and thrombotic complications. There are several bedside whole blood microcoagulation systems available to determine activated clotting time (ACT) levels. Many ECMO centers use Hemochron (International Technidyne, Edison, NJ) products to determine ACT levels. During the study period, we used the Hemochron 400 and then changed to the Hemochron Junior Low Range. There were two specific aims of this study. First, to determine if there was a difference in ACT levels measured by these two distinct Hemochron products both marketed for the use in ECMO therapy. Second, to determine if the differing ACT levels produced by these two devices affected clinical outcomes. We compared ACT levels between two devices on 70 paired blood specimens obtained from four neonatal ECMO patients receiving heparin. A retrospective review of 77 ECMO patients was performed to analyze frequency of circuit emergencies and length of ECMO circuit life while using the two products. In lower ACT ranges, the Hemochron Jr. LR consistently yielded higher ACT values than the Hemochron 400. In higher ACT ranges, the Hemochron Jr. LR consistently yielded lower ACT values than the Hemochron 400. Without calibration, after changing devices, this discrepancy led to shorter circuit life and more circuit clotting complications. After calibration and adjustment in target ACT values, there was a trend toward longer circuit life, and there were fewer clotting complications. There is a difference in the ACT values produced by Hemochron 400 and Hemochron Jr. LR. Failure to calibrate target ACT levels after changing machines may lead to shorter circuit life and more clotting complications.
The purpose of this study was to evaluate the content validity and construct validity of a novel electronic fetal monitor (EFM) simulator. Fourteen residents in Gynecology and Obstetrics (OB/GYN) and 7 medical students in their OB/GYN clerkship interpreted 10 fetal heart rate (FHR) tracings and 4 clinical scenarios generated by the EFM simulator. Their responses were scored by experts in maternal-fetal medicine. Construct validity was determined by comparing subjects' scores to their level of experience. Subjects assessed content validity of the EFM simulator by rating the realism of its various elements on a 4-point Likert scale. Residents achieved statistically significant higher mean scores in the description of FHR tracings generated by the simulator than medical students and statistically significant higher mean scores in the correct interpretation of and interventions in 2 of 4 clinical scenarios. Two-thirds of the residents rated the simulator-generated FHR tracings and clinical scenarios as "real" or "very real." The EFM simulator exhibited both content and construct validity, supporting its use in an educational setting.
BACKGROUND/PURPOSE: Liquid ventilation is a promising therapy for respiratory failure. The effects of perfluorochemical on cardiac output have not been well described. The purpose of this study was to compare cerebral blood flow (Q(CAROTID)) and cerebral metabolic rates (CMR) during conventional ventilation (CV) and partial liquid ventilation (PLV). METHODS: Five 2-week-old lambs underwent tracheostomy and central venous, aortic, and postcerebral venous catheter placement. Doppler flow probes were placed around the common ovine trunk, and the lambs underwent CV for 1 hour. Ventilation was adjusted to maintain physiologic blood gases. Pre- and postcerebral blood gas, glucose, and lactate samples were obtained every 15 minutes. Perfluorodecalin then was instilled endotracheally. The lambs underwent 1 hour of PLV with similar sampling. Data were analyzed using the Wilcoxon matched pairs test, significance at P </=.05. RESULTS: The authors observed no difference in mean Q(CAROTID) or carotid vascular resistance between CV and PLV (P =.35 and.34, respectively). The CMR of oxygen, glucose, and lactate were calculated using the Fick principle. CMR was unchanged between modes (P =.5). CONCLUSIONS: PLV did not adversely alter Q(CAROTID) or CMR in lambs, implying that this mode of ventilation should be safe in neonatal patients at risk for neurologic injury.