The authors have no acknowledgements.

All methods described here were found to be exempt from review by the Indiana University Institutional Review Board.
1. Preparation
<ol>
	<li>E-mail the GRIEV_ING pocket card (Figure 1) to all faculty one week prior to the scheduled simulation session.</li>
	<li>E-mail the death notification simulation scenarios (<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61646/JoVE RCDP Standardized Patient Case Materials.docx" target="_blank">Supplement 1</a>), that include patient role and background history, to the standardized patients one week prior to the scheduled simulation session.</li>
	<li>Prepare the simulation examination rooms prior to beginning the death notification simulation exercise.
	<ol>
		<li>Place a chair for the standardized patient and a stool for the learner in each examination room.</li>
		<li>Print patient scenario information (<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61646/JoVE RCDP Patient Scenario Information door note.docx" target="_blank">Supplement 2</a>), which includes name, age, gender, background, present condition and survivor present, and post outside each exam room for learners. Have faculty read death notification scenarios prior to the start of the session.</li>
	</ol>
	</li>
</ol>
2. Rapid Cycle Deliberate Practice GRIEV_ING Simulation Exercise Pre-brief
<ol>
	<li>Gather all faculty and learners in one room. Review the simulation session goals and objectives.</li>
	<li>Review logistic details about RCDP and the simulation environment.</li>
	<li>Form a fiction contract with the learners and pledge to respect the learners.&#160; 
	NOTE: A fiction contract is an agreement between the educators and learners. This creates the expectation that educators attempt to create as realistic of simulation environment as possible while the learners pretend that things are real and actively participate in the educational experience14.</li>
	<li>Divide the learners into groups of no more than 4-5 learners.</li>
	<li>Assign each learner group an examination room with a faculty member and standardized patient.</li>
	<li>Give each learner a GRIEV_ING pocket card to reference during the simulation (Figure 1).</li>
</ol>
3. Rapid Cycle Deliberate Practice GRIEV_ING Simulation Exercise
<ol>
	<li>Select one learner from each group to perform the initial death notification scenario.</li>
	<li>Position the standardized patient in the exam room. Have the learners to review the simulation scenario case details posted outside the exam room.</li>
	<li>Start the initial death notification scenario. Run the scenario from start to finish without interruption. Identify specific areas that necessitate feedback.</li>
	<li>Perform a micro-debriefing at the conclusion of first scenario. Give succinct feedback to learners on initial performance in less than 5 minutes.</li>
	<li>Reset the scenario and place the learners outside the room. Perform the same simulation scenario from the beginning. Begin with the same learner as the leader for the second round of the scenario.</li>
	<li>Apply the RCDP technique during the scenario. Pause the scenario, provide directed feedback and then rewind the scenario 30-60 seconds. Have the standardized patient to restart the scenario. 
	NOTE: In order to allow multiple students to participate in a single scenario, faculty can switch out the participating learner by &#8220;tagging in&#8221; observing students to continue the scenario. For example, if John started the scenario, faculty can stop, give feedback and rewind the scenario. Faculty then &#8220;tags in&#8221; Sam to resume the scenario as the new active participant from where John left off. Faculty should make sure all learners have an opportunity to be in the &#8220;hot seat&#8221; throughout the allotted training time.</li>
	<li>Perform a micro-debriefing at the conclusion of the scenario training period. Provide constructive feedback to the learners.</li>
	<li>Repeat the scenario again from the start and continue with the RCDP approach. 
	NOTE: The goal is to need less interruptions each time the scenario is performed. The RCDP simulation exercise requires 45-50 minutes.</li>
</ol>
4. Rapid Cycle Deliberate Practice GRIEV_ING Wrap Up
<ol>
	<li>Gather all faculty and learners in one room for a group wrap-up at the conclusion of the simulation training. Focus on key take-home points from the training and allow for learner feedback during the 15 minute wrap-up.</li>
</ol>

<ol>
	<li>National Hospital Ambulatory Medical Care Survey: 2016 Emergency Department Summary Tables. Centers for Disease Control and Prevention Available from: <a target="_blank" href="https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf">https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf</a> (2016)</li><li>Waiters, D. T., Tupin, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Family+grief+in+the+emergency+department.">Family grief in the emergency department.</a> Emergency Medicine Clinics of North America. 9 (1), 189-206 (1991).</li><li>Breslau, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trauma+and+posttraumatic+stress+disorder+in+the+community:+the+1996+Detroit+area+survey+of+trauma.">Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma.</a> Archives of General Psychiatry. 55 (7), 626-632 (1998).</li><li>Stewart, A. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complicated+bereavement+and+posttraumatic+stress+disorder+following+fatal+car+crashes:+recommendations+for+death+notification+practice.">Complicated bereavement and posttraumatic stress disorder following fatal car crashes: recommendations for death notification practice.</a> Death Studies. 23 (4), 289-321 (1999).</li><li>Shoenberger, J. M., Yeghiazarian, S., Rios, C., Henderson, S. O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Death+Notification+in+the+Emergency+Department:+survivors+and+physicians.">Death Notification in the Emergency Department: survivors and physicians.</a> Western Journal of Emergency Medicine. 14 (2), 181-185 (2013).</li><li>Park, I., Gupta, A., Mandani, K., Haubner, L., Peckler, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Breaking+bad+news+education+for+emergency+medicine+residents:+A+novel+training+module+using+simulation+with+the+SPIKES+protocol.">Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol.</a> Journal of Emergencies, Trauma, and Shock. 3 (4), 385-388 (2010).</li><li>Hobgood, C., Harward, D., Newton, K., Davis, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+educational+intervention+"GRIEV_ING"+improves+the+death+notification+skills+of+residents.">The educational intervention "GRIEV_ING" improves the death notification skills of residents.</a> Academic Emergency Medicine. 12 (4), 296-301 (2005).</li><li>Chancey, R. J., Sampayo, E. M., Lemke, D. S., Doughty, C. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Learners'+Experience+During+Rapid+Cycle+Deliberate+Practice+Simulations:+A+Qualitative+Analysis.">Learners' Experience During Rapid Cycle Deliberate Practice Simulations: A Qualitative Analysis.</a> Simulation in Healthcare. 14 (1), 18-28 (2019).</li><li>Hunt, E. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pediatric+resident+resuscitation+skills+improve+after+"rapid+cycle+deliberate+practice"+training.">Pediatric resident resuscitation skills improve after "rapid cycle deliberate practice" training.</a> Resuscitation. 85 (7), 945-951 (2014).</li><li>Taras, J., Everett, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rapid+Cycle+Deliberate+Practice+in+Medical+Education-+a+Systematic+Review.">Rapid Cycle Deliberate Practice in Medical Education- a Systematic Review.</a> Cureus. 9 (4), 1180 (2017).</li><li>Ahmed, R. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rapid+Cycle+Deliberate+Practice:+Death+Notification.">Rapid Cycle Deliberate Practice: Death Notification.</a> The Clinical Teacher. , (2020).</li><li>Stephenson, E., Poore, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tips+for+Conducting+the+Pre-Brief+for+a+Simulation.">Tips for Conducting the Pre-Brief for a Simulation.</a> The Journal of Continuing Education in Nursing. 47 (8), 353-355 (2016).</li><li>Rudolph, J. W., Raemer, D. B., Simon, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Establishing+a+safe+container+for+learning+in+simulation:+the+role+of+the+presimulation+briefing.">Establishing a safe container for learning in simulation: the role of the presimulation briefing.</a> Simulation in Healthcare. 9 (6), 339-349 (2014).</li><li>Hughes, P. G., Hughes, K. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Briefing+Prior+to+Simulation+Activity.">Briefing Prior to Simulation Activity.</a> StatPearls. , (2020).</li></ol>

The authors have nothing to disclose.

The RCDP death notification curriculum consists of several critical steps. First, the prebrief is critical to introduce the concept of RCDP and create psychological safety for learners. Learners who feel psychologically safe have less anxiety and feel more comfortable making mistakes, allowing for optimization of the learning experience13,14,15. In addition, the curriculum requires that educators provide learners with an overview of the GRIEV_ING framework and death notification materials prior to the simulation session. This allows the students to be more engaged in the simulation and use the session to refine death notification skills. Each learner is given a GRIEV_ING pocket card during simulation session. Learners in an observational role are able to follow along and remain actively engaged. Possible modifications of this simulation protocol include altering group size or providing the GRIEV_ING pocket card to the learners prior to the event.
During the simulation, a key step is running the first death notification scenario from start to finish without interruption. This needs assessment displays the learner&#8217;s baseline skill and enables the faculty member to identify areas of weakness and provides a roadmap when subsequently implementing the RCDP technique. RCDP provides the student an opportunity to incorporate the feedback provided and demonstrate optimal performance. It allows learners to practice through repetition with expert feedback and direct coaching. Faculty can correct performance gaps while maximizing the time spent practicing. This has been shown to increase learning without cognitive overload9.
Lastly, it is critical to repeat the same scenario again from the start and continue with the RCDP approach. The goal is to have fewer interruptions each time the scenario is performed. This allows learners to continuously improve throughout the simulation session and leads to mastery9,10,11. This differs from traditional simulation training in that faculty can immediately visualize improvement in performance.
There are few limitations to executing the RCDP death notification curriculum. This exercise does not require any particular equipment or setup. It does require one standardized patient per every 4-5 learners. Standardized patients should be trained and have experience playing the role of a grieving patient. This training includes acting methods on how to accurately portray psychosocial characteristics and emotions. It can be provided by the simulation staff or standardized patient liaison. In addition, faculty must be knowledgeable in RCDP in order to use this technique successfully in the training. Lack of faculty with formal simulation training and experience using RCDP creates practice variation. This introduces subjectivity into the training experience.
Currently, there is limited literature on improving delivery of bad news using RCDP. This innovative technique allows learners to rewind and practice each part of the scenario until mastery is achieved. Future directions for this study include assessment of skill retention using the RCDP technique, directly comparing this technique to traditional simulation approaches, and investigating how this curriculum translates to effectiveness of death notification in the clinical environment.

Death notification is an important and challenging aspect of Emergency Medicine. An emergency medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. On average 270,000 patients die in United States emergency departments each year1. This number is anticipated to increase as the population ages2. Unskilled death notification can lead to the development of pathologic grief and posttraumatic stress disorder3,4,5. It is paramount for emergency medicine physicians to be trained in and practice death notification.
Graduate and undergraduate medical educators employ a variety of death notification techniques when teaching residents and medical students to deliver bad news6,7,8. One example is the GRIEV_ING curriculum. It provides medical personnel a conceptual framework for death notification. The curriculum has demonstrated improvement in learners&#8217; confidence and competence when delivering bad news8.
Rapid Cycle Deliberate Practice (RCDP) is a simulation-based medical education technique that uses within-scenario debriefing9. This technique is based on the concepts of mastery learning and deliberate practice9,10,11. It allows educators to pause a scenario, provide directed feedback, and then let learners rewind and continue the simulation scenario the &#8220;right way.&#8221; The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news12.
In preparation for this curriculum, learners are given a 45-minute lecture on the principles of death notification and the GRIEV_ING conceptual framework. Prior to starting the simulation session, faculty perform a prebrief of the objectives, RCDP and simulation environment logistic details, establish a fiction contract with the learners and pledge to respect the learners13,14,15. The learners are split into groups of 4-5 and assigned an examination room with a faculty member and standardized patient. Each learner is given a GRIEV_ING pocket card to reference during the simulation. To start, one learner is selected from each group to perform the first death notification scenario. This first death notification serves as a needs assessment for the faculty. It is allowed to run from start to finish without interruption. Next, the same learner performs a new death notification simulation using the same scenario, this time RCDP is used by the faculty to provide feedback throughout the death notification scenario. Faculty pause the scenario, provide directed feedback and then rewind the scenario 30-60 seconds. The scenario is then restarted by the standardized patient.

<table>
	<tbody>
		<tr>
			<td>Chair</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Facial Tissues</td>
			<td></td>
			<td></td>
			<td>Standardized patients will need for simulated crying</td>
		</tr>
		<tr>
			<td>GRIEV_ING pocket card</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Stool</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

setup and execution of the rapid cycle deliberate practice death notification curriculum

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. Unskilled death notification after unexpected events can lead to the development of pathologic grief and posttraumatic stress disorder. It is paramount for Emergency Medicine physicians to be trained in and practice death notification techniques. The GRIEV_ING curriculum provides a conceptual framework for death notification. The curriculum has demonstrated improvement in learners&#8217; confidence and competence when delivering bad news. Rapid Cycle Deliberate Practice is a simulation-based medical education technique that uses within the scenario debriefing. This technique uses the concepts of mastery learning and deliberate practice. It allows educators to pause a scenario, provide directed feedback, and then let learners continue the simulation scenario the &#8220;right way.&#8221; The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news.

As noted in Ahmed et al., the study involved 22 emergency medicine residents12. Learners&#8217; median self-efficacy and knowledge scores increased from 3 to 4 and 65 to 90, respectively, when comparing pre- and post-simulation results. In addition, pre- and post-intervention death notification performance scores improved (Table 1).
Qualitative themes from the post-curriculum surveys by Ahmed et al. were that this exercise was a great experience and provided instant feedback12. Residents felt the RCDP Death Notification Curriculum solidified their death notification skills and allowed them the opportunity to refine their technique. Only one resident preferred the tradition simulation method with no interruptions.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/61646/61646fig01.jpg" /> 
Figure 1: GRIEV_ING pocket card.&#160;Pocket card with overview of GRIEV_ING curriculum. This figure has been modified from research by Ahmed et al.12. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61646/61646fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Pre</td>
			<td>Post</td>
			<td>P-Value*</td>
		</tr>
		<tr>
			<td>Self-efficacy Survey</td>
			<td>3.0 (3.0-4.0)</td>
			<td>4.0 (4.0-5.0)</td>
			<td>&#60;0.0001</td>
		</tr>
		<tr>
			<td>MCQ Scores</td>
			<td>65.0 (40.0-80.0)</td>
			<td>90.0 (80.0-90.0)</td>
			<td>&#60;0.0001</td>
		</tr>
		<tr>
			<td></td>
			<td>Case A</td>
			<td>Case B</td>
			<td>P-Value*</td>
		</tr>
		<tr>
			<td>Death Notification Scores</td>
			<td>78.7 (72.3-85.1)</td>
			<td>84.0 (80.9-93.6)</td>
			<td>0.0303</td>
		</tr>
		<tr>
			<td colspan="4">*estimated using Wilcoxon</td>
		</tr>
	</tbody>
</table>
Table 1: RCDP Death Notification Curriculum results. Scores from participants (N=22). Median pre- and post- scores were calculated. Wilcoxon rank sum test was used to test for score differences between pre- and post-intervention groups. All statistical analysis was performed using SAS Version 9.4. This table has been modified from research by Ahmed et al.12.

Watch this Scientific Journal Video about Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum at JoVE.com

Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum

The goal is to demonstrate how to apply the rapid cycle deliberate practice debriefing technique to the GRIEV_ING death notification curriculum.

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and ...

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4.1K 조회수.  Florida Atlantic University Schmidt College of Medicine. The goal is to demonstrate how to apply the rapid cycle deliberate practice debriefing technique to the GRIEV_ING death notification curriculum.

비디오: Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum

Cell Death Associated with Abnormal Mitosis Observed by Confocal Imaging in Live Cancer Cells

Phenanthrene derivatives acting as potent PARP1 inhibitors prevented the bi-focal clustering of supernumerary centrosomes in multi-centrosomal human cancer cells in mitosis. The phenanthridine PJ-34 was the most potent molecule. Declustering of extra-centrosomes causes mitotic failure and cell death in multi-centrosomal cells. Most solid human cancers have high occurrence of extra-centrosomes. The activity of PJ-34 was documented in real-time by confocal imaging of live human breast cancer MDA-MB-231 cells transfected with vectors encoding for fluorescent &gamma;-tubulin, which is highly abundant in the centrosomes and for fluorescent histone H2b present in the chromosomes. Aberrant chromosomes arrangements and de-clustered &gamma;-tubulin foci representing declustered centrosomes were detected in the transfected MDA-MB-231 cells after treatment with PJ-34. Un-clustered extra-centrosomes in the two spindle poles preceded their cell death. These results linked for the first time the recently detected exclusive cytotoxic activity of PJ-34 in human cancer cells with extra-centrosomes de-clustering in mitosis, and mitotic failure leading to cell death. According to previous findings observed by confocal imaging of fixed cells, PJ-34 exclusively eradicated cancer cells with multi-centrosomes without impairing normal cells undergoing mitosis with two centrosomes and bi-focal spindles. This cytotoxic activity of PJ-34 was not shared by other potent PARP1 inhibitors, and was observed in PARP1 deficient MEF harboring extracentrosomes, suggesting its independency of PARP1 inhibition. Live confocal imaging offered a useful tool for identifying new molecules eradicating cells during mitosis.

The cytotoxic activity of the phenanthridine PJ-34 in cancer cells undergoing mitosis was documented in real time by live confocal imaging. PJ-34 eradicated human breast cancer MDA-MB-231 cells harboring extra-centrosomes in mitosis. Unlike normal bi-focal mitosis, the extra-centrosomes were not clustered in the two spindle poles in the presence of PJ-34.

비정상적인 유사 분열과 관련된 세포의 죽음은 라이브 암 세포의 공 촛점 이미징에 의해 관찰

Phenanthrene derivatives acting as potent PARP1 inhibitors prevented the bi-focal clustering of supernumerary centrosomes in multi-centrosomal human ...

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의학

Imaging- and Flow Cytometry-based Analysis of Cell Position and the Cell Cycle in 3D Melanoma Spheroids

Three-dimensional (3D) tumor spheroids are utilized in cancer research as a more accurate model of the in vivo tumor microenvironment, compared to traditional two-dimensional (2D) cell culture. The spheroid model is able to mimic the effects of cell-cell interaction, hypoxia and nutrient deprivation, and drug penetration. One characteristic of this model is the development of a necrotic core, surrounded by a ring of G1 arrested cells, with proliferating cells on the outer layers of the spheroid. Of interest in the cancer field is how different regions of the spheroid respond to drug therapies as well as genetic or environmental manipulation. We describe here the use of the fluorescence ubiquitination cell cycle indicator (FUCCI) system along with cytometry and image analysis using commercial software to characterize the cell cycle status of cells with respect to their position inside melanoma spheroids. These methods may be used to track changes in cell cycle status, gene/protein expression or cell viability in different sub-regions of tumor spheroids over time and under different conditions.

We describe two complementary methods using the fluorescence ubiquitination cell cycle indicator (FUCCI) and image analysis or flow cytometry to identify and isolate cells in the inner G1 arrested and outer proliferating regions of 3D spheroids.

Imaging- 및 유동 세포 계측법 기반의 셀 위치의 분석 및 3D 흑색 종 회전 타원체의 세포주기

Three-dimensional (3D) tumor spheroids are utilized in cancer research as a more accurate model of the in vivo tumor microenvironment, compared to ...

An Improved Method for Rapid Intubation of the Trachea in Mice

Despite some anatomical and physiological differences, mouse models continue to be an essential tool for studying human lung disease. Bleomycin toxicity is a commonly used model to study both acute lung injury and fibrosis, and multiple methods have been developed for administering bleomycin (and other toxic agents) into the lungs. However, many of these approaches, such as transtracheal instillation, have inherent drawbacks, including the need for strong anesthetics and survival surgery. This paper reports a quick, reproducible method of intratracheal intubation that involves mild inhaled anesthesia, visualization of the trachea, and the use of a surrogate spirometer to confirm exposure. As a proof of concept, 8-12 week old C57BL/6 mice were administered either 2.0 U/kg of bleomycin or an equivalent volume of PBS, and both damage and fibrotic endpoints were measured post-exposure. This procedure allows researchers to treat a large cohort of mice in a relatively short period with little expense and minimal post-procedure care.

This article presents a rapid and simple method for administering bleomycin directly into the mouse trachea via intubation. Key advantages of this method are that it is highly reproducible, easy to master, and does not require specialized equipment or lengthy recovery times.

마우스의기도 신속 삽관 용 개선 된 방법

Despite some anatomical and physiological differences, mouse models continue to be an essential tool for studying human lung disease. Bleomycin toxicity ...

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

로봇 수술에 긴급 도킹 해제: 시뮬레이션 커리큘럼

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of ...

Mechanical Ventilation Boot Camp Curriculum

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased morbidity and mortality. A three-day simulation-based boot camp serves to provide one-on-one instruction with a critical care provider. These intensivists may dispense personalized immediate feedback as learners engage in hands-on practice with a real mechanical ventilator. Multiple different pathologies can be reviewed that may not be encountered in the clinical setting. Learners can visualize immediate consequences of their actions and may troubleshoot and ask questions, all while in a safe learning environment. We describe the use of human-patient simulators connected to breathing simulators and mechanical ventilators. Potential curriculum executors should be aware of the cost of the equipment and the time needed to dedicate to boot camp execution; however, this intensive interactive training has been shown to increase provider competency, knowledge, and confidence in ventilator management. This curriculum outline provides guidance on how to execute a simulation-based boot camp to train providers on the management of mechanically ventilated patients.

This curriculum outlines how to execute a simulation-based boot camp to teach providers how to manage mechanically ventilated patients.

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased ...

Setup and Execution Of the Blindfolded Code Training Exercise

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to improve resident physician communication and leadership strategies in high-acuity situations. The blindfolded code training exercise removes visual stimuli from the team leader, forcing the team leader to effectively utilize closed-loop communication. The simple act of blindfolding the team leader creates a learning environment where the leader must utilize a conceptual framework and critical thinking strategies to organize the team and manage the resuscitation. An advantage to this teaching technique is that it does not require any special simulation equipment, making it a low-cost approach. The blindfolded code training exercise can be applied to the management of any critically ill patient where the primary objective is to focus on developing communication skills in acute resuscitations. The purpose of the description of the blindfolded code training exercise is to provide guidance on how to perform this innovative teaching technique to force effective closed-loop communication.

The blindfolded code training exercise, which blindfolds the team leader in a code resuscitation simulation, is an advanced teaching technique to improve closed-loop communication, organizational skills, and critical thinking.&#160;

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to ...

A New Best Practice for Validating Tail Vein Injections in Rat with Near-infrared-Labeled Agents

Intravenous (IV) administration of agents into the tail vein of rats can be both difficult and inconsistent. Optimizing tail vein injections is a key part of many experimental procedures where reagents need to be introduced directly into the bloodstream. Unwittingly, the injection can be subcutaneous, possibly altering the scientific outcomes. Utilizing a nanoemulsion-based biological probe with an incorporated near-infrared fluorescent (NIRF) dye, this method offers the capability of imaging a successful tail vein injection in vivo. With the use of a NIRF imager, images are taken before and after the injection of the agent. An acceptable IV injection is then qualitatively or quantitatively determined based on the intensity of the NIRF signal at the site of injection.

Here we present a method to validate tail vein injections in rats by utilizing near-infrared fluorescence imaging data from dyes incorporated into agents or biological probes. The tail is imaged before and after the injection, the fluorescent signal is quantified, and an assessment of the injection quality is made.

근처-적외선-표시 에이전트와 쥐의 꼬리 정 맥 주사의 유효성 검사에 대 한 새로운 좋습니다

Intravenous (IV) administration of agents into the tail vein of rats can be both difficult and inconsistent. Optimizing tail vein injections is a key part ...

Pre-clinical Model of Cardiac Donation after Circulatory Death

Cardiac transplantation demand is on the rise; nevertheless, organ availability is limited due to a paucity of suitable donors. Organ donation after circulatory death (DCD) is a solution to address this limited availability, but due to a period of prolonged warm ischemia and the risk of tissue injury, its routine use in cardiac transplantation is seldom seen. In this manuscript we provide a detailed protocol closely mimicking current clinical practices in the context of DCD with continuous monitoring of heart function, allowing for the evaluation of novel cardioprotective strategies and interventions to decrease ischemia-reperfusion injury.
In this model, the DCD protocol is initiated in anesthetized Lewis rats by stopping ventilation to induce circulatory death. When systolic blood pressure drops below 30 mmHg, the warm ischemic time is initiated. After a pre-set warm ischemic period, hearts are flushed with a normothermic cardioplegic solution, procured, and mounted onto a Langendorff ex vivo heart perfusion system. Following 10 min of initial reperfusion and stabilization, cardiac reconditioning is continuously evaluated for 60 min using intraventricular pressure monitoring. A heart injury is assessed by measuring cardiac troponin T and the infarct size is quantified by histological staining. The warm ischemic time can be modulated and tailored to develop the desired amount of structural and functional damage. This simple protocol allows for the evaluation of different cardioprotective conditioning strategies introduced at the moment of cardioplegia, initial reperfusion and/or during ex vivo perfusion. Findings obtained from this protocol can be reproduced in large models, facilitating clinical translation.

This protocol shows a simple and flexible approach for the evaluation of new conditioning agents or strategies to increase the feasibility of cardiac donation after circulatory death.

순환사망 후 심장 기증 전 임상 모델

Cardiac transplantation demand is on the rise; nevertheless, organ availability is limited due to a paucity of suitable donors. Organ donation after ...

Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index

When randomized controlled trials are not feasible, retrospective studies using big data provide an efficient and cost-effective alternative, though they are at risk for treatment selection bias. Treatment selection bias occurs in a non-randomized study when treatment selection is based on pre-treatment characteristics that are also associated with the outcome. These pre-treatment characteristics, or confounders, can influence evaluation of a treatment&#39;s effect on the outcome. Propensity scores minimize this bias by balancing the known confounders between treatment groups. There are a few approaches to performing propensity score analyses, including stratifying by the propensity score, propensity matching, and inverse probability of treatment weighting (IPTW). Described here is the use of IPTW to balance baseline comorbidities in a cohort of patients within the US Military Health System Data Repository (MDR). The MDR is a relatively optimal data source, as it provides a contained cohort in which nearly complete information on inpatient and outpatient services is available for eligible beneficiaries. Outlined below is the use of the MDR supplemented with information from the national death index to provide robust mortality data. Also provided are suggestions for using administrative data. Finally, the protocol shares an SAS code for using IPTW to balance known confounders and plot the cumulative incidence function for the outcome of interest.

Inverse Probability of Treatment Weighting Propensity Score using the Military Health System Data Repository and National Death Index

When randomized controlled trials are not feasible, a comprehensive health care data source like the Military Health System Data Repository provides an attractive alternative for retrospective analyses. Incorporating mortality data from the national death index and balancing differences between groups using propensity weighting helps reduce biases inherent in retrospective designs.

군 보건 시스템 데이터 저장소 및 국가 사망 지수를 사용하여 치료 가중치의 역 확률 (성향 점수)

When randomized controlled trials are not feasible, retrospective studies using big data provide an efficient and cost-effective alternative, though they ...

Clinical Practice Protocol of Creative Music Therapy for Preterm Infants and Their Parents in the Neonatal Intensive Care Unit

Creative music therapy for preterm infants and their parents (CMT) has emerged as a promising family-integrated early intervention involving communicative musicality to improve infant development, parental well-being, and bonding. It aims at relaxing and nurturing the infant as well as promoting safety and social interaction for the parent-infant dyad. A music therapist specially trained in CMT hums or sings in an infant-directed, improvised, lullaby style continually adjusting to the individual needs, expressions, and breathing pattern of the preterm infant. Based on the principles of family-integrated care, the family is incorporated individually in the therapeutic process, namely by delivering CMT during kangaroo care (KC) and by motivating and facilitating parental vocal interaction with their infant to strengthen the parent-infant bonding. CMT aims at relaxing, stimulating, and coregulating premature infants at a time when many other interventions are still risky and can overwhelm the vulnerable patient group. CMT may be advantageous not by educating and teaching parents, but rather by uncovering the intuitive capacities of parenting that are often overshadowed by the traumatic experience of preterm birth. However, CMT can only be provided when the infants are clinically stable. CMT with parental integration is feasible when parents are available and receptive to participate. This paper presents a detailed protocol on how to use CMT to empower preterm infants and their families.

Creative music therapy for preterm infants and their parents has emerged as a promising family-integrated early intervention. We present a detailed protocol on how to use vocal interaction, humming, or singing to empower preterm infants and their families.

신생아 중환자실에서 조산아와 부모를 위한 창의적인 음악 치료의 임상 실습 프로토콜

Creative music therapy for preterm infants and their parents (CMT) has emerged as a promising family-integrated early intervention involving communicative ...