Teaching airway management skills. How and what to learn and teach

It is important to instruct all individuals involved in patient care in airway management. The degree of skills actually taught depends on the student. Currently, there are many options for teaching. Mannequin training is the one best suited to instruct a large number of students in a variety of skills. Training of surgical and obstetric residents improves relations, may improve patient safety, and educates these individuals regarding the risks of failed intubation. Actual clinical decisions regarding patient management are based on the airway examination. There is room for improvement in instruction, even in anesthesiology programs. Various techniques must be taught and practiced. As more anesthesiologists become trained and then train other physicians, the number of cases in the Closed Claims Study involving the airway will continue to decrease.     

Airway clearance strategies for the pediatric patient

Clinicians who care for cystic fibrosis (CF) patients have many techniques to choose from to facilitate mucus clearance. Little has been published about when to introduce the various techniques and in what order to teach them. Debates have occurred over these issues in the CF community, and there is now consensus on some topics. It is very important to teach adherence to therapy at an early age. Adherence to an airway clearing regimen assists in maintaining good pulmonary function in CF patients. Knowing when and how to introduce airway clearance techniques beyond chest physiotherapy (CPT) is clinically relevant and useful. A 5-position modified CPT routine can be used with infants and children, and it takes less time and may improve adherence. Infants and toddlers can be taught breathing games that eventually lead them to perform diaphragmatic breathing and huffing. Once they have mastered diaphragmatic breathing and huffing, children can be taught the active cycle of breathing technique. Modified CPT can be phased out at that point. Positive expiratory pressure therapy can usually be introduced around 6-7 years of age. High-frequency chest wall oscillation, oscillating positive expiratory pressure, and autogenic drainage all follow. CF patients should be given every opportunity to learn and master various techniques to promote mucus clearance.     

Email etiquette: guidelines for mental health nurses

This note is about the use of email and its role in mental health settings. We anticipate that it may be of assistance to mental health nurses unfamiliar with the benefits and pitfalls of email and wanting to learn more about how to use it professionally and effectively. In mental health nursing, we pride ourselves on our interpersonal skills and being able to communicate. However, transferring these skills to an electronic medium is not always easy. Because many of us are self-taught, there is potential for email to be a hindrance rather than a help in the quest for good collegial relationships. In this note, we discuss some of the common situations that can arise when email use goes awry and provide some helpful tips for getting the most out of email. It is hoped that the information and checklist provided in this paper will strike a chord with many, encouraging discussion and promoting appropriate use of this form of communication.     

How do you size a nasopharyngeal airway

OBJECTIVE: To measure an appropriately sized nasopharyngeal airway, it is taught that the size is related to the patients little finger or nostril (anterior nares). This study has been designed to identify whether these comparisons are valid. METHOD: Direct comparison of the dimensions of ten subjects' little fingers and anterior nares with the internal anatomy of their nose as visualised on coronal MRI scans. RESULTS: Neither method correlated statistically with the nasal anatomy of that subject. CONCLUSIONS: The methods used traditionally to size a nasopharyngeal airway do not correlate with the airway anatomy and are unreliable. It is more appropriate to size the airway dependent upon the patient's size, sex and race.     

Faculty mentorship: support for nurse practitioner students and staff within the rural community health setting

As pointed out in the introduction, there are certain practical concepts within our base of nursing knowledge that can only be taught through experience. Many things are easier to teach by example. As we turn back the clock in nursing, we can see how Florence Nightingale, Clara Barton, and Lillian Wald were role models to their nursing peers in their era. They taught nursing by example, by role modeling their clinical expertise. Today, this model is still effective and faculty mentoring of nurse practitioner students and CHNs in a compassionate and collegial leadership results in higher quality of health care for our nation's needy clients and their families. But greater yet are the opportunities for flexible nurse practitioner faculty practice and personal interactions on many levels for nursing faculty who wish to share their expertise. Mentorship by nurse practitioner faculty for nurse practitioner students and CHNs in a rural clinical setting has revealed many positive aspects in providing quality care for rural clients and growth for nurses. Exposure to the rural community health system helps us, as nurses, to identify the many strengths it possesses for innovative rural nursing practice.     

Pitfalls in migraine diagnosis and management

The decade of the 90s brought about a revolution in our understanding of migraine and in medications to treat this disorder. Indeed, our understanding of the pathophysiology of migraine and the pharmacology involved in its treatment has exploded. Nonetheless, there are still many pitfalls that may occur in the clinical assessment and management of migraine that may prevent the patient from receiving the full benefits of the advances of the past 10 years. This article explores the reasons for the unsuccessful diagnosis and treatment of migraine and presents suggestions for improving its management.     

The focused abdominal sonography for trauma scan: pearls and pitfalls.

OBJECTIVE: To review the state-of-the-art use of sonography in evaluating the patient with trauma. METHODS: We reviewed our experience in performing more than 5000 sonographic examinations in the patient with trauma. The recent experience of other publications advocating newer applications of sonography in the patient with trauma are discussed and presented in a pictorial fashion. RESULTS: The main focus of sonography in the patient with trauma has been in performance of the focused abdominal sonography for trauma scan. The focused abdominal sonography for trauma scan is usually performed in the patient with blunt abdominal trauma and is used to check for free fluid in the abdomen or pelvis. There are certain pitfalls that need to be avoided and certain limitations of the focused abdominal sonography for trauma scan that need to be recognized. These pitfalls and limitations are reviewed. More recently, sonography has been used to detect certain solid-organ injuries that have a variety of appearances. Thus, sonography may be used to localize the specific site of injury in these patients. More recently, sonography has been used to evaluate thoracic abnormalities in patients with trauma, including pleural effusions, pneumothoraces, and pericardial effusions. CONCLUSIONS: The use of sonography in evaluating the patient with trauma has rapidly expanded in the past decade. Those using sonography in this group of patients should be aware of its many uses but also its potential pitfalls and limitations.     

MOTOR RESTLESSNESS

Motor restlessness, characterised by an irresistible urge to move about, can be a manifestation of many underlying disorders. Unfortunately, it is often poorly recognised and underdiagnosed in clinical practice, possibly because patients do not seek medical attention, or their complaints were thought to be secondary to anxiety. While the two major conditions to consider are restless legs syndrome and neuroleptic-induced akathisia, there are many other differential diagnoses. We provide a concise review of the clinical features and diagnostic pitfalls of these conditions. A proper detailed clinical history and examination can often help clinch the diagnosis, as most of these conditions have their unique clinical features.     

Ten pitfalls in the proper management of patients with hyponatremia

Hyponatremia (serum sodium <135 mEq/L) is a common electrolyte disorder in community or hospitalized patients. Serum sodium levels should be corrected at a proper rate in patients with hyponatremia, since overcorrection of serum sodium levels is related to devastating neurologic consequences, such as the osmotic demyelination syndrome (ODS). However, a number of pitfalls, which could lead to undercorrection or overcorrection of hyponatremia, are common during the treatment of hyponatremic patients. Hereby, we describe ten common pitfalls that are observed during the correction of serum sodium concentration in hyponatremic patients. These refer to pitfalls in the goals and limits of the correction rate of serum sodium, pitfalls in the means (e.g. solutions but also drugs) and formulas used for achieving the desired correction rate and pitfalls associated with inadequate management or overcorrection. The knowledge of these common-in-clinical-practice pitfalls could assist clinicians in the proper management of patients with hyponatremia.     

How we perform myocardial perfusion with cardiovascular magnetic resonance.

Cardiovascular magnetic resonance first-pass perfusion imaging has developed considerably over the past decade. Several studies have shown that this technique is accurate for the detection of myocardial ischemia. In this article we outline the procedure of myocardial perfusion imaging with cardiovascular magnetic resonance as it is performed at our centers, describe the sequences that are currently used in more detail, review our process of image interpretation, and highlight potential pitfalls that we have encountered in our experience with performing this technique in over 2000 patients.     

Forced expiratory technique, directed cough, and autogenic drainage

In health, secretions produced in the respiratory tract are cleared by mucociliary transport, cephalad airflow bias, and cough. In disease, increased secretion viscosity and volume, dyskinesia of the cilia, and ineffective cough combine to reduce secretion clearance, leading to increased risk of infection. In obstructive lung disease these conditions are further complicated by early collapse of airways, due to airway compression, which traps both gas and secretions. Techniques have been developed to optimize expiratory flow and promote airway clearance. Directed cough, forced expiratory technique, active cycle of breathing, and autogenic drainage are all more effective than placebo and comparable in therapeutic effects to postural drainage; they require no special equipment or care-provider assistance for routine use. Researchers have suggested that standard chest physical therapy with active cycle of breathing and forced expiratory technique is more effective than chest physical therapy alone. Evidence-based reviews have suggested that, though successful adoption of techniques such as autogenic drainage may require greater control and training, patients with long-term secretion management problems should be taught as many of these techniques as they can master for adoption in their therapeutic routines.     

Achievement of group cohesion through the development of a psychiatric nursing seminar

The purpose of this paper is to describe the process by which group cohesion emerged around the task of developing a psychiatric nursing seminar at the Palo Alto (California) V.A. Medical Center. This paper will discuss how group cohesion evolved, describe the seminar, and offer suggestions to other nurses wanting to work together more collaboratively. As clinical nurse specialists (CNS) assigned to the inpatient psychiatric units of a Veterans Administration Medical Center, we were asked by nursing administration to develop an educational course. The purpose of the course was to provide registered nurses with a common knowledge base that would facilitate communication related to patient care. While we were aware that teaching discreet areas of content commensurate with our individual interests and expertise would get the job done rapidly, our combined experience taught us that this approach to learning did little to bring about a change in clinical practice. We viewed the selection of a conceptual framework to which we could all be committed as an essential step prior to the content development. What is significant about this experience was that the group process of achieving cohesiveness was so closely related to the conceptual framework that finally evolved. We chose a framework that reflected our own perspectives towards working with others and about psychiatric nursing. In turn, the major concepts of the chosen framework guided many of our interactions with each other.     

Nursing and the current situation of complementary treatments

The present situation in nursing is one of a clear advance, as the result of the search which more and more nurses consider: a real end to nursing, "the treatments" to maintain health or to recuperate it. To this end, we should make use of all the useful methods available to us. We know that with a caress of our hands we loose endorphins which help reduce pain, that music relaxes us, that color illuminates our lives, that reflexology frees us from tensions, and that, definitely, we have available to us a large number of resources which offer relief and well-being to our patients without secondary efforts, and at a low cost. These supplementary non-specialized health treatments are taught in a non-systematic manner and an optional manner in Spanish nursing schools. Nursing professionals demonstrate great interest in alternative therapies and many nurses are specialists in some of these today. However, in spite of the fact that alternative therapies are included in current study programs, scientific production by Spanish nurses en these fields is scarce. The research and development guidelines published as priorities by the Carlos III Institute and by the European Health Committee do no reflect the study of these treatment methods in a specific manner; but we have the opportunity in our own hands to demonstrate by means of our own research the extent of the benefits which these therapies may provide.     

Complementary and Alternative Medicine: Challenge to eCAM

Our new journal eCAM, Evidenced-based Complementary and AlternativeMedicine has just celebrated a major milestone since its birthin 2004. Conceived and incubated in Kanazawa, Japan and bornat UCLA, Los Angeles with assistance from Oxford UniversityPress. With this editorial, we enter our third volume; eCAMis 2 years old, i.e. two volumes that are hard copy. Electronicsubmission and peer reviewing hasten publication by advanceaccess before the appearance of a hard copy issue. Althoughthese points may be old news to some, our international travelshave taught us that many of our potential authors and readersare unaware of these publication policies and mechanisms. Moreover,it seems not universally understood that because we are youngwe are still waiting for an impact factor. Happily     

医疗大数据的“欺骗性”及其对策

当前,针对医疗大数据的研究和应用越来越广泛,但毋庸置疑,医疗大数据本身具有一定欺骗性,在某些特殊场景下,可能会产生错误的结论和影响。本文从数据本身的欺骗性以及机器学习可能存在的陷阱展开,对医疗大数据产生欺骗性的原因进行分析;针对医疗大数据的欺骗性,从统计学角度阐述如何避免大数据陷阱;从模型角度分析模型被攻击的应对策略以及模型可解释性在医疗领域的重要性和方法。     

Retention of cricothyrotomy skills by paramedics using a wire guided technique

Introduction

Cricothyrotomy may be necessary for airway management when a patient's airway cannot be maintained through standard techniques such as oral airway placement, blind insertion airway device, or endotracheal intubation. Wire-guided cricothyrotomy is one of many techniques used to perform a cricothyrotomy. Although there is some controversy over which cricothyrotomy technique is superior, there is no published data regarding long term retention rates. The purpose of this study is to determine whether ground based paramedics can be taught and are able to retain the skills necessary to successfully perform a wire-guided cricothyrotomy.

Management of pediatric airway--anatomy, physiology and new developments in clinical practice

Due to the special features of paediatric anatomy and physiology, the expected and unexpected difficult paediatric airway is one of the major challenges to every anaesthesiologist, paediatrician and emergency physician. During the last years, some new devices have been made available to improve airway management in children and infants, and several studies have advanced our understanding of the risks and benefits of our clinical practice. Certain risk factors for airway related problems during anaesthesia in children having a "cold" have been identified, and there are new aspects of the controversy concerning the use of cuffed endotracheal tube (ETT) in children. New video assisted systems have been introduced for the management of the difficult airway in paediatric patients, and new applications for well-known devices have been suggested, e.g. the laryngeal mask airway (LMA) serving as guidance for fibreoptic intubation. Recent studies have also demonstrated specific problems with the LMA in infants, as well as possible advantages of a new prototype LMA for children, similar to the ProSeal. Furthermore, the following review presents data about the use of the Cuffed Oropharyngeal Airway (COPA) and the Laryngeal Tube (LT) in paediatric patients.     

"In memoriam"

For too long members of the helping professions have let our own emotional needs go unmet. Taught in school to provide postmortem care for the deceased and consoling words for the family, we were never taught to grieve for our patients.     

Introducing integrative East-West medicine to medical students and residents

Over the last several years, many medical schools and residencies have introduced complementary and alternative medicine (CAM) into their curricula, prompting a discussion as to how CAM should be taught. In this paper, we share our experiences teaching medical trainees integrative East-West medicine, an approach to health and disease that brings together modern Western and Chinese medicine. A 2-week clinical rotation that is intimately tied to our busy clinical program is described in detail as we explore some of the challenges and opportunities involved in teaching a CAM-related field to medical trainees. We also demonstrate how such a clinical experience offers an opportunity to impart on our students a broad view of medicine and to discuss novel approaches to clinical problem-solving.