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The use of Airway Pressure Release Ventilation (APRV) in patients with traumatic brain injury (TBI) remains controversial. Some believe that elevated mean airway pressures transmitted to the thorax may cause clinically significant increases in Central Venous Pressure (CVP) and intracranial pressure (ICP) from venous congestion. We perform a retrospective review from 2009 to 2015 of traumatically injured patients who were transitioned from traditional ventilator modes to APRV and also had an ICP monitor in place. Fifteen patients undergoing 19 transitions to APRV were identified. Prior to transitioning to APRV the average static and dynamic compliance was 22.9 +/− 5.6 and 16.5 +/− 4.12 mL/cm H2O. There was no statistical difference in ICP, MAP, and CPP prior to and after transition to APRV. There was a statistically significant increase in CVP, PaO2, and P:F ratio. Individually, only 4 patients had ICP values >20 in the first hour after transitioning to APRV and the rate of ICP elevations was similar between the two modes of ventilation. These data show that APRV is a viable mode of ventilation in patients with TBI who have low lung compliance. The increased CVP of this mode of ventilation did not affect ICP or hemodynamic parameters.

PurposeClinical disaster medicine requires providers working collaboratively to care for multiple patients, yet many clinicians lack competency-based training. A 5-hour emergency preparedness training (EPT) curriculum was created using didactics, small group discussion, and scenario-based learning. The goal was to evaluate the effect of a short course on improving clinical-provider knowledge, confidence and skill.MethodsParticipants were enrolled in a medical university between 2011 and 2014. The course consisted of didactic lectures, small group exercises, and live mass-casualty training scenarios. Core competencies and performance objectives were developed by a task force and assessed via facilitator observation, pre- and posttesting, and a course evaluation.ResultsA total of 708 participants were trained, including 49.9% physicians, 31.9% medical students, 7.2% nurses, and 11% allied health personnel. The average percentage of correct answers increased from 39% to 60% (PConclusionA brief, intensive EPT course can improve the disaster knowledge and comfort level of a diverse group of clinical providers as well as foster disaster-performance skills. (Disaster Med Public Health Preparedness. 2018;12:121–126)

ObjectiveProviding comprehensive emergency preparedness training (EPT) to care providers is important to the future success of disaster operations in the US. Few EPT programs possess both competency-driven goals and metrics to measure performance during a multi-patient simulated disaster.MethodsA 1-day (8-hour) EPT course for care providers was developed to enhance provider knowledge, skill, and comfort necessary to save lives during a simulated disaster. Nine learning objectives, 18 competencies, and 34 performance objectives were developed. During the 2-year demonstration of the curriculum, 24 fourth-year medical students and 17 Veterans Hospital Administration (VHA) providers were recruited and volunteered to take the course (two did not fully complete the research materials). An online pre-test, two post-tests, course assessment, didactic and small group content, and a 6-minute clinical casualty scenario were developed. During the scenario, trainees working in teams were confronted with three human simulators and 10 actor patients simultaneously. Unless appropriate performance objectives were met, the simulators “died” and the team was exposed to “anthrax.” After the scenario, team members participated in a facilitator-led debriefing using digital video and then repeated the scenario.ResultsTrainees (N = 39) included 24 (62%) medical students; seven (18%) physicians; seven (18%) nurses; and one (3%) emergency manager. Forty-seven percent of the VHA providers reported greater than 16 annual hours of disaster training, while 15 (63%) of the medical students reported no annual disaster training. The mean (SD) score for the pre-test was 12.3 (3.8), or 51% correct, and after the training, the mean (SD) score was 18.5 (2.2), or 77% (P< .01). The overall rating for the course was 96 out of 100. Trainee self-assessment of “Overall Skill” increased from 63.3 out of 100 to 83.4 out of 100 and “Overall Knowledge” increased from 49.3 out of 100 to 78.7 out of 100 (P< .01). Of the 34 performance objectives during the disaster scenario, 23 were completed by at least half of the teams during their first attempt. All teams except one (8 of 9) could resuscitate two simulators and all teams (9 of 9) helped prevent anthrax exposure during their second scenario attempt.ConclusionsThe 1-day EPT course for novice and experienced care providers recreated a multi-actor clinical disaster and enhanced provider knowledge, comfort level, and EPT skill. A larger-scale study, or multi-center trial, is needed to further study the impact of this curriculum and its potential to protect provider and patient lives.ScottLA,SwartzentruberD,DavisCA,MadduxPT,SchnellmanJ,WahlquistAE.Competency in chaos: lifesaving performance of care providers utilizing a competency-based, multi-actor emergency preparedness training curriculum.Prehosp Disaster Med.2013;28(4):1-12.

The lack of emergency preparedness training (EPT) for patient care providers—including clinicians, hospital workers, mental health providers, public safety and law enforcement officials, community volunteers, EMS, HAZMAT and fire personnel—poses significant risks to both patients and patient care providers. During the 1995 Tokyo sarin gas attacks, for example, up to 80% of patients bypassed first responders and reported directly to hospitals where hospital staff suffered secondary exposure to sarin due to inadequate personal protective equipment (PPE) and training.1 Furthermore, during Hurricane Katrina, the lack of EPT was cited as a significant factor contributing to adverse patient outcomes.2–7 Providing comprehensive EPT for medical trainees—including medical, nursing students and other health care trainees—is important to the future success of emergency preparedness operations in the US.8–15 Just weeks prior to the 9/11 terrorist attacks, an American College of Emergency Physicians (ACEP) task force published recommendations for medical students to develop skill-based EPT competencies for nuclear, biological, and chemical incidents.16 Immediately after 9/11, a report by the Association of American Medical Colleges (AAMC)—and later by the Institute of Medicine (IOM)—encouraged early introduction of bioterrorism topics in medical schools.17–18 Unfortunately, US medical schools have been slow to develop stand-alone EPT curricula.17, 19 Few medical schools have defined and implemented EPT core competencies for health professionals19–20 and newly developed EPT programs have largely focused on practicing clinicians and not trainees.21–24 Disasters are rare, complex events involving many patients and environmental factors that are difficult to reproduce inside a classroom. Recent reviews suggest that health care worker EPT programs lack clarity, objectivity, competency-driven goals, scientific rigor, prospective validation, and consistency across medical specialties.25–28 In a prior study, we revealed how medical students can value and rapidly learn some core EPT elements via a novel addition to a medical school’s curriculum.19, 29 Students who completed our 3-hour ‘Disaster 101’ curriculum vastly increased their overall knowledge and comfort level with EPT skills. A significant limitation of our study was the relatively simplistic measurement of EPT performance. In one scenario, students were required to rapidly triage 100 life-sized inflatable mannequins tagged with physical parameters indicating respiratory, circulatory, and mental status. It was suggested from the curriculum review that the validity and reliability of the EPT performance measurement would be better suited in a controlled environment, such as the university human patient simulation laboratory, in which a combination of live actors and human simulated patients could reproduce the ‘chaos’ associated with a clinical disaster. It was further suggested that high fidelity patient simulators could help us evaluate the impact of our EPT on patient outcomes, for example, whether trainees could appropriately triage and intervene medically to save a life. Here we described the development of a human simulation-based EPT curriculum for patient care providers that recreates a chaotic clinical disaster through a combination of up to 15 live actors and 6 high-fidelity human simulators. Specifically, we detail the Center for Health Professional Training and Emergency Response’s (CHPTER’s) one-day clinical EPT course—provided first to medical students, then to a group of experience disaster medical providers—including its organization, core competency and content development, medical student self evaluation and course assessment. To our knowledge, this is the first published description of a curriculum method that combines high-fidelity, multi-actor scenarios to measure the life-saving performance of patient care providers during a moderately-sized clinical disaster (> 10 patients at once). Curriculum Development—Organization In 2009, CHPTER was formed as South Carolina’s first collaborative EPT center for health professionals (www.musc.edu/chpter). A community-wide advisory committee of emergency preparedness stakeholders—including regional hospitals, NGO’s, public health officials, EMS and law enforcement agencies—met to establish goals for CHPTER to enhance regional health security. CHPTER’s established a mission to enhance regional health security and surge capability by giving patient care providers hands-on lessons that will protect and save patient lives during a disaster. A curriculum task force of the CHPTER Advisory Committee consisting of health professional and emergency preparedness experts met and decided: 1) the EPT course should be no greater than 1 day to ensure increased attendance from busy trainees and other patient care providers, 2) the curriculum should be directed toward the general medical trainee, defined broadly as any patient care provider during a disaster, so it could develop into an interdisciplinary experience 3) the curriculum should be interactive and case-based so trainees could recognize the relevance of disaster medicine knowledge and clinical skills to their work place; 4) human simulation and multi-patient encounters should be used to create realistic clinical disasters; and 5) research metrics should be developed to measure trainee skill acquisition and performance to save lives during a disaster. The task force hypothesized that the newly proposed EPT course would improve patient care provider knowledge, skills, and comfort level necessary to save lives during a disaster. The task force evaluated existing competency objectives and domains from a course given to 4th year university medical students in 2008 and 2009.19, 29 Additional competency and evaluative frameworks considered included those from the Veteran’s Health Administration (VHA), the American Medical Association’s Center for Public Health Preparedness and Disaster Response, the Agency for Health Care Research and Quality (AHRQ), Columbia University and others.30–35

Background: Despite efforts to improve preparedness training for health professionals, disaster medicine remains a peripheral component of traditional medical education in the United States (US) and is a rarely studied topic in the medical literature. Objectives: Using a pre-/post-test design, we measured the extent to which 4 th -year medical students perceive, rapidly learn, and apply basic concepts of disaster medicine via a novel curriculum. Methods: Via a modified Delphi technique, an expert curriculum panel developed a 90-min didactic training scenario and two 40-min training exercises for medical students: a hazardous material scene and a surprise mass casualty incident (MCI) scenario with 100 life-sized mannequins. Medical students were quizzed before and after the didactic training scenario about their perceptions and their disaster medicine knowledge. Results: Students rated their overall knowledge as 3.76/10 pretest compared to 7.64/10 after the didactic program. Students' post-test scores improved by 54% and students participating in the MCI drill correctly tagged 94% of the victims in approximately 10 min. The average overall rating for the experience was 4.85/5. Conclusions: The results of this educational demonstration project reveal that students will value and can rapidly learn some core elements of disaster medicine via a novel addition to a medical school's curriculum. We believe the principle of a highly effective and well-received medical student course that can be easily added to a university curriculum has been demonstrated. Further research is needed to validate core competencies and performance-based education goals for US health professional trainees.

Objectives: To describe the incidence and etiology of meningitis among patients presenting to the emergency department (ED) who undergo lumbar puncture (LP) and to describe clinical criteria to select which adult patients would not need an LP because the likelihood of meningitis is low. Materials and Methods: This was a retrospective chart review of the results of LPs performed in a tertiary care ED from March to October 2003 on patients aged 16 to 50 years suspected of having meningitis. Using the electronic record, we recorded presenting symptoms, comorbidities, results of (cerebrospinal fluid) analysis, ED length of stay, and complications. The association between specific physical examination or laboratory findings and meningitis was determined through the calculation of sensitivity, specificity, and negative/positive predictive values. Results: Data from the results of 164 LPs were analyzed. Eleven patients (6.7%) had meningitis confirmed by gram stain, culture, or DNA analysis. The causative agents included 55% viral (2 enterovirus, 2 herpes simplex virus, 1 varicella, and 1 coxsackie), 27% bacterial (1 coagulase-negative Staphylococcus aureus, 1 rickettsial, and 1 syphilis) and 18% parasitic/fungal (1 cysticercosis and 1 Cryptococcus neoformans). The most common presenting symptoms or comorbidities in patients receiving an LP were headache (75.6%), fever (47.6%), neck pain or stiffness (23.8%), HIV (11.6%), a history of migraine headaches (4.9%), or a history of cancer or chemotherapy (4.9%). No combination of clinical criteriaVincluding the absence of the classic triad of headache, neck stiffness, and altered mental statusVruled out meningitis. Cerebrospinal fluid findings such as pleocytosis and lymphocytic predominance were strongly associated with meningitis (P = 0.0003 and 0.0004, respectively). Patients receiving an LP stayed in the ED 48.6% longer than other ED patients, and 10 patients (6.1%) returned to the ED within 1 week complaining of headache. Conclusions: In this study, no clinical criteria were identified to select which adult patients would not need an LP because the likelihood of meningitis is low. The absence of fever, neck stiffness, and altered mental status did not rule out adult meningitis. More research may be needed to evaluate the need for adding antiviral agents to the standard regimen when treating presumptive meningitis on adults in the ED. More research is needed to risk stratify adult patients and improve the utilization of LPs in the ED. (Infect Dis Clin Pract 2008;16:298Y302)

OBJECTIVES This article details the development of the Center for Health Professional Training and Emergency Response (CHPTER), including its innovative, competency-based emergency preparedness training (EPT) curriculum, and the results of a regional preparedness workforce assessment. METHODS CHPTER was established in 2009 with the goal of enhancing regional health security and patient surge competency by offering patient care providers, including clinicians and volunteers, hands-on lessons that will protect and save lives during a disaster. A 1-day emergency preparedness training (EPT) course that includes a loud, chaotic clinical disaster scenario was developed. A two-part workforce assessment survey to further refine regional EPT needs was administered. RESULTS The 1-day EPT course enhanced patient care providers' knowledge, comfort level, and skills required to save lives during a disaster. Twenty-one emergency department directors and 400 patient care providers responded to the surveys. The majority of emergency department directors surveyed believe that one in five of their provider workforce would fail to properly perform their expected duties in a disaster. More than half of the patient care providers reported fewer than 2 hours of annual EPT training and 40% of employers required no annual training. The most significant barriers to widespread dissemination of EPT were financial constraints and time availability of providers. CONCLUSIONS Patient care providers in our region (North and South Carolina) are not prepared for a disaster. The CHPTER 1-day competency-based EPT curricula improved trainee knowledge, comfort level, and disaster care skills. CHPTER may serve as a model for other regions seeking to improve care provider EPT programs.

The frequency of milk-alkali syndrome decreased rapidly after the development of histamine-2 antagonists and proton pump inhibitors for the treatment of peptic ulcer disease; however, the availability and overconsumption of antacids and calcium supplements can still place patients at risk (D. P. Beall et al., 2006). Here we describe a patient who presented with altered mental status, hypercalcemia, metabolic alkalosis, and acute renal failure in the context of ingesting large amounts of antacids to control dyspepsia.

To measure the verbal communication between emergency medical technician-paramedics (EMT-Ps) and physicians in an emergency department trauma room (EDTR) before and after an educational intervention.Using a before-after design, we audio-recorded paramedic verbal trauma reports in a large EDTR over a 12-week period. Trained research assistants subsequently queried physicians about information from the paramedic report in a separate interview. Physician recall was quantified. Midway through the study, a web-based, educational intervention designed to enhance paramedic communication skills was administered to the three participating emergency medical services (EMS) systems. Physician recall of more severely injured trauma cases (red triage) was compared with their recall of less severely injured cases (yellow triage). Further comparisons were made between pre- and post-intervention physician recalls, and the extent to which physicians recalled three distinct categories of paramedic verbal information was measured.Overall, physicians accurately recalled 36% of the paramedic verbal report. Information from less severe "yellow" trauma reports was recalled more accurately than that from more severe "red" traumas (40% vs. 34% p = 0.02). Pre- and post-intervention recalls were not significantly different (33% vs. 38% p = 0.16). Physicians' recall of information about the crash scene (46%) was significantly greater than their recall of information about the patient's health status (34%) or information about prehospital patient care (30%) (p = 0.0012).Physicians appear to recall paramedic verbal reports about trauma patients poorly. Recall is probably multifactorial and will require further work to design appropriate interventions.