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In this panel, we present perspectives on how to incorporate fundamental concepts in resilience engineering into health care human-in-the-loop simulations. Our panelists have successfully implemented concepts, but also continue to experience challenges with convincing colleagues of the importance and value of doing so for simulations that have other training, technology evaluation, or quality improvement objectives.

The disaster management cycle is an accepted model that encompasses preparation for and recovery from large-scale disasters. Over the past decade, India's Pediatric Simulation Training and Research Society has developed a national-scale simulation delivery platform, termed the Simulathon, with a period prevalence methodology that integrates with core aspects of this model. As an exemplar of the effectiveness of this approach, we describe the development, implementation, and outcomes of the 2020 Simulathon, conducted from April 20 to May 20 in response to the nascent COVID-19 pandemic disaster. We conclude by discussing how aspects of the COVID-19 Simulathon enabled us to address key aspects of the disaster management cycle, as well as challenges that we encountered. We present a roadmap by which other simulation programs in low- and middle-income countries could enact a similar process.

Anesthesiologists and otolaryngologists share the airway in an elegant ballet that requires communication, collaboration, and mutual respect. This article addresses principles to prevent or manage challenging conditions such as airway fires, anatomically difficult airways, and post-tonsillectomy hemorrhage. Discussion includes rationales for the use of simulation and resilience engineering principles to achieve the safest patient care.

Surgeons can use simulation to improve the safety of the systems they work within, around, because of, and despite. Health care is a complex adaptive system that can never be completely knowable; simulation can expose aspects of patient care delivery that are not necessarily evident prospectively, during planning, or retrospectively, during investigations or audits. The constraints of patient care processes and adaptive capacity of health care providers may become most evident during simulations conducted “in situ” using real teams and real equipment, in actual patient care locations.

Attempts to understand and improve health care delivery often focus on the characteristics of the patient and the characteristics of the health care providers, but larger systems surround and integrate with patients and providers. Components of health care delivery systems can support or interfere with efforts to provide optimal health care. Simulation in situ, involving real teams participating in simulations in real care settings, can be used to identify latent safety threats and improve the work environment while simultaneously supporting participant learning. Thoughtful planning and skilled debriefing are essential.

Published ahead of print February 15, 2017.Learning to use a new electronic anesthesia information management system can be challenging. Documenting anesthetic events, medication administration, and airway management in an unfamiliar system while simultaneously caring for a patient with the vigilance required for safe anesthesia can be distracting and risky. This technical report describes a vendor-agnostic approach to training using a high-technology manikin in a simulated clinical scenario. Training was feasible and valued by participants but required a combination of electronic and manual components. Further exploration may reveal simulated patient care training that provides the greatest benefit to participants as well as feedback to inform electronic health record improvements.

OBJECTIVES To confirm interrater reliability using blinded evaluation of a skills-assessment instrument to assess the surgical performance of resident and fellow trainees performing pediatric direct laryngoscopy and rigid bronchoscopy in simulated models. DESIGN Prospective, paired, blinded observational validation study. SUBJECTS Paired observers from multiple institutions simultaneously evaluated residents and fellows who were performing surgery in an animal laboratory or using high-fidelity manikins. The evaluators had no previous affiliation with the residents and fellows and did not know their year of training. INTERVENTIONS One- and 2-page versions of an objective structured assessment of technical skills (OSATS) assessment instrument composed of global and a task-specific surgical items were used to evaluate surgical performance. RESULTS Fifty-two evaluations were completed by 17 attending evaluators. The instrument agreement for the 2-page assessment was 71.4% when measured as a binary variable (ie, competent vs not competent) (κ = 0.38; P = .08). Evaluation as a continuous variable revealed a 42.9% percentage agreement (κ = 0.18; P = .14). The intraclass correlation was 0.53, considered substantial/good interrater reliability (69% reliable). For the 1-page instrument, agreement was 77.4% when measured as a binary variable (κ = 0.53, P = .0015). Agreement when evaluated as a continuous measure was 71.0% (κ = 0.54, P < .001). The intraclass correlation was 0.73, considered high interrater reliability (85% reliable). CONCLUSIONS The OSATS assessment instrument is an effective tool for evaluating surgical performance among trainees with acceptable interrater reliability in a simulator setting. Reliability was good for both the 1- and 2-page OSATS checklists, and both serve as excellent tools to provide immediate formative feedback on operational competency.

This study investigates whether laryngoscope motion-tracking technology can be used to differentiate expert versus novice providers' techniques during endotracheal intubation in infant manikins; this may help improve intubation techniques.

Objectives/Hypothesis:Gastroesophageal reflux disease (GERD) is common in children, and extraesophageal reflux disease (EORD) has been implicated in the pathophysiology of otitis media (OM). We sought to 1) determine the incidence of pepsin/pepsinogen presence in the middle ear cleft of a large sample of pediatric patients undergoing myringotomy with tube placement for OM; 2) compare this with a control population of pediatric patients undergoing middle ear surgery (cochlear implantation) with no documented history of OM; 3) analyze potential risk factors for OM in children with EORD demonstrated by the presence of pepsin in the middle ear cleft; and 4) determine if pepsin positivity at the time of myringotomy with tube placement predisposes to posttympanostomy tube otorrhea.

OBJECTIVE To evaluate the perceived value of aerodigestive endoscopy training using high-fidelity simulation. DESIGN Self-reported survey. SETTING Pediatric tertiary care hospital. PARTICIPANTS Consecutive sample of otolaryngology residents and 1 fellow during the 2006-2007 academic year. INTERVENTIONS Foreign body aspiration and ingestion were simulated in a high-fidelity, computer-assisted infant simulation mannequin. Avoidance of complications and successful removal required teamwork and responsiveness to the mannequin's physiologic characteristics in addition to dexterity with instruments. MAIN OUTCOME MEASURES Postcourse 5-point Likert scale and subjective evaluation of perceived realism reported by participants. RESULTS Participant response was generally positive. Ratings were highest for training cognitive and psychomotor endoscopy skills, preventing and managing complications, and facilitating team process. Overall realism and appropriate “feel” showed opportunity for improvement. CONCLUSION Pediatric otolaryngology trainees perceive that high-fidelity patient simulation facilitates acquisition of aerodigestive endoscopy skills, especially in training cognitive and psychomotor endoscopy skills, preventing and managing complications, and facilitating team process.Arch Otolaryngol Head Neck Surg. 2008;134(6):625-629--

Penetrating middle ear injury can result in hearing loss, vertigo, and facial nerve injury. We describe the cases of 2 children with penetrating trauma to the right ear that resulted in ossicular chain disruption; one injury was caused by cotton-tipped swabs and the other by a wooden matchstick. Symptoms in both children included hearing loss and otalgia; in addition, one child experienced ataxia and the other vertigo. Physical examination in both cases revealed a perforation in the posterosuperior quadrant of the tympanic membrane and visible ossicles. Audiometry identified a moderate conductive hearing loss in one child and a mild sensorineural hearing loss in the other. Both children underwent middle ear exploration and reduction of a subluxed stapes. We discuss the diagnosis, causes, and management of penetrating middle ear trauma. To reduce the morbidity associated with these traumas, otologic surgeons should act promptly and be versatile in choosing methods of repairing ossicular chain injuries.

The objective of this study was to determine the incidence of vocal problems in young choir singers and to correlate vocal problems with demographic and behavioral information. A questionnaire addressing vocal habits and hygiene was offered to 571 young choir singers, up to 25 years of age, who sing at least weekly; 129 (22.6%) responded. More than one-half of the respondents had experienced vocal difficulty, particularly older adolescents. Detrimental behaviors and circumstances surveyed were not reflective of the incidence of vocal difficulty, except for morning hoarseness, chronic fatigue, insomnia, and female gender after puberty. Voice care professionals should be aware that self-reported voice difficulties are common among young choral singers, especially postpubescent girls, and children with symptoms consistent with reflux (morning hoarseness) and emotional stress (insomnia). Laryngologists should communicate with choral conductors and singing teachers to enhance early identification and treatment of children with voice complaints, and to develop choral educational strategies that help decrease their incidence.

Intermediate-duration middle ear ventilation appears to be a good treatment option for selected children with otitis media. Laser-assisted myringotomy is one way to provide such ventilation. It can provide prompt pain relief and resolution of middle ear effusion and effusion-related hearing loss, and it can provide an opportunity for surveillance of antibiotic-resistant organisms. We performed laser-assisted myringotomy on 97 ears of 54 children over a 5-month period. All children had acute or recurrent otitis media or persistent middle ear effusions. Our experience suggests that laser-assisted myringotomy is a feasible treatment option for selected patients. Practitioner experience and patient and family considerations will contribute to the decision whether to use general or topical anesthesia.

OBJECTIVE: To determine the efficacy of transdermal clonidine hydrochloride for prophylaxis of withdrawal syndromes that are common following more than 7 days of deep sedation after single-stage laryngotracheal reconstruction (LTR) surgery. DESIGN: Consecutive case series. SETTING: Pediatric intensive care unit at tertiary care referral center, university-affiliated children's hospital. PATIENTS: Ten consecutive patients who had undergone single-stage LTR and received sedation with a combination of narcotics and benzodiazepines. INTERVENTIONS: A sustained release transdermal clonidine hydrochloride patch (50-100 μg/d; mean, 5.8 μg/kg per day; range, 4.2-8.5 μg/kg per day) was applied to 8 consecutive patients before discontinuation of sedative infusions and elective extubation. Physicians continued to treat patients for withdrawal symptoms, if seen, at their discretion. MAIN OUTCOME MEASURES: Seventeen characteristic narcotic and sedative withdrawal symptoms recorded at baseline and serially for at least 48 hours following discontinuation of deep sedation. RESULTS: No severe symptoms of narcotic or sedative withdrawal (seizure, choreoathetosis, tremors, or dehydration) were seen in any patient during treatment with clonidine. Not more than 2 minor withdrawal symptoms (lethargy and respiratory rate >40 breaths/min) occurred simultaneously during treatment with clonidine in any patient. Two of 8 patients had clonidine patches removed prematurely. Both patients experienced withdrawal symptoms within hours, and these symptoms subsided in the 1 patient whose clonidine patch was reinstituted. No significant sustained side effects, bradycardia, or dysrhythmia necessitated discontinuation of clonidine therapy, and no rebound withdrawal was seen with routine discontinuation of clonidine after 7 days of therapy. CONCLUSIONS: Transdermal clonidine prophylaxis may be a safe and efficacious adjunct to prevent withdrawal symptoms in pediatric patients who have undergone single-stage LTR. Use of a validated withdrawal symptom scoring tool is indicated for patients undergoing single-stage LTR and requiring prolonged, deep sedation in the pediatric intensive care unit.Arch Otolaryngol Head Neck Surg. 1996;122:1234-1238

Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported.

• Angioneurotic edema involving the uvula is sometimes referred to as Quincke's edema. The term angioneurotic edema describes several closely related diseases manifested by recurrent, acute edema of the skin or mucosa. We report a case of uvular edema secondary to food allergy, treated successfully with steroids. A short review of angioneurotic edema and its management is also presented.(Arch Otolaryngol Head Neck Surg. 1991;117:100-102)