Effectively controlling the spread of contagious illnesses has become a critical focus of disaster planning. It is likely that quarantine will be a key part of the overall public health strategy utilised during a pandemic, an act of bioterrorism or other emergencies involving contagious agents. While the United States lacks recent experience of large-scale quarantines, it has considerable accumulated experience of large-scale evacuations. Risk perception, life circumstance, work-related issues, and the opinions of influential family, friends and credible public spokespersons all play a role in determining compliance with an evacuation order. Although the comparison is not reported elsewhere to our knowledge, this review of the principal factors affecting compliance with evacuations demonstrates many similarities with those likely to occur during a quarantine. Accurate identification and understanding of barriers to compliance allows for improved planning to protect the public more effectively.

Objectives: The incidence of posterior vessel wall puncture (PVWP) during central line placement with possible subsequent injury to structures lying behind the vein is unknown. At times the internal jugular vein lies immediately anterior to the carotid artery rather than lateral to it, leading to potential arterial puncture should the needle pass through the vein completely. The objective of this study is to evaluate the incidence of PVWP during simulated ultrasound (US)-guided vessel cannulation.Methods: Enrolled subjects were emergency medicine resident and attending physicians. Subjects performed US-guided venous access on simulated blood vessels within gelatin-based US phantoms. While blinded to the purpose of the study, each subject performed successful cannulation of the vessel on separate phantoms, with wire placement confirmed by expert review of a follow-up US. Each phantom was subsequently deconstructed to manually inspect for PVWP.Results: Thirty-five subjects with a range of experience in the technique participated, each performing both transverse and long-axis approaches for a total of 70 cannulations. The overall incidence of PVWP was 34% (95% confidence interval [CI] = 22.9% to 45.1%).Conclusions: This study found a high incidence of inadvertent PVWP during simulated US-guided vessel cannulation in this model. ACADEMIC EMERGENCY MEDICINE 2010; 17:1138-1141 ª 2010 by the Society for Academic Emergency MedicineKeywords: ultrasonography, shock, critical care, emergency medicine, patient simulation A rterial puncture during central venous catheter placement is a known complication of the procedure, with reported incidence up to 11%. 1,2While ultrasound (US) guidance has been shown in several studies to decrease arterial puncture, 1-3 the identification of this event is based on the presence of forceful, pulsatile blood flow from the needle after removal of the syringe. Occult arterial injuries occur when the artery is punctured during the course of the procedure without resultant pulsatile flow through the needle.4 Both recognized and occult arterial injuries may result in significant complications.When using a landmark technique for internal jugular venous access, many practitioners intentionally pass through-and-through the vessel and access the lumen when withdrawing the needle. The use of US allows for direct visualization of the internal jugular vein and internal carotid artery, but commonly demonstrates the vein superficial to the artery. 5 In this scenario, any posterior vessel wall puncture (PVWP) that occurs could result in arterial injury. The objective of this study was to measure the incidence of PVWP during US-guided vessel cannulation using a phantom model. METHODS Study DesignThis was an observational study to assess the incidence of PVWP in a simulated model. The study was approved by the institutional review board.

Results indicate the course did effect a change in students' attitudes to teaching as evident from comments such as, 'I will be a better teacher because I have been given the appropriate tools'.

IntroductionWork interruptions during patient care have been correlated with error. Task-switching is identified by the Accreditation Council for Graduate Medical Education (ACGME) as a core competency for emergency medicine (EM). Simulation has been suggested as a means of assessing EM core competencies. We assumed that senior EM residents had better task-switching abilities than junior EM residents. We hypothesized that this difference could be measured by observing the execution of patient care tasks in the simulation environment when a patient with a ST-elevation myocardial infarction (STEMI) interrupted the ongoing management of a septic shock case.MethodsThis was a multi-site, prospective, observational, cohort study. The study population consisted of a convenience sample of EM residents in their first three years of training. Each subject performed a standardized simulated encounter by evaluating and treating a patient in septic shock. At a predetermined point in every sepsis case, the subject was given a STEMI electrocardiogram (ECG) for a separate chest pain patient in triage and required to verbalize an interpretation and action. We scored learner performance using a dichotomous checklist of critical actions covering sepsis care, ECG interpretation and triaging of the STEMI patient.ResultsNinety-one subjects participated (30 postgraduate year [PGY]1s, 32 PGY2s, and 29 PGY3s). Of those, 87 properly managed the patient with septic shock (90.0% PGY1s, 100% PGY2, 96.6% PGY 3s; p=0.22). Of the 87 who successfully managed the septic shock, 80 correctly identified STEMI on the simulated STEMI patient (86.7% PGY1s, 96.9% PGY2s, 93.1% PGY3s; p=0.35). Of the 80 who successfully managed the septic shock patient and correctly identified the STEMI, 79 provided appropriate interventions for the STEMI patient (73.3% PGY1s, 93.8% PGY2s, 93.8% PGY3s; p=0.07).ConclusionWhen management of a septic shock patient was interrupted with a STEMI ECG in a simulated environment we were unable to measure a significant difference in the ability of EM residents to successfully task-switch when compared across PGY levels of training. This study may help refine the use of simulation to assess EM resident competencies.

No abstract