Training of Physicians in Advanced Life Support for Children

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Training of Physicians in Advanced Life Support
for Children

• Deena R Zimmerman MD MPH

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Every Physicians Nightmare
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But Most Physicians Are Unprepared

• Lack of knowledge
• Pediatric residents
• Family physicians
• Lack of equipment
• General emergency departments
• Offices

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Lack of KnowledgePediatric residents

• Telephone survey of 73 pediatric residents in
  Wales
• Problem subjects percentage correct
• Compromised upper airway (55)
• Fluid management of hemorrhagic shock (49)
• Only (26) mentioned the intra-osseous route as a
  means of obtaining vascular access in a child in
  extremis.
• Low confidence (41)
• Need more formal training (94)
• Buss PW, McCabe M, Evans RJ, Davies A, Jenkins H.
  A survey of basic resuscitation knowledge among
  resident paediatricians. Arch Dis Child. 1993
  Jan68(1)75-8.

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Lack of KnowledgePediatric Residents

• A telephone questionnaire of 57 residents to test
  their knowledge of European Resuscitation Council
  guidelines.
• Correct sequence of management for asystole (26)
• Correct use of adrenaline (14)
• Identification of ventricular fibrillation (32)
• Buss PW, Evans RJ, McCarthy G, Scorrer T, Kumar
  V.Paediatricians' knowledge of cardiac arrest
  guidelines. Arch Dis Child. 1996 Jan74(1)47-9.

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Lack of KnowledgeFamily Physicians

• Questionnaires to 169 community practices
  regularly treating children
• Average 4 or more pediatric emergencies in a year
  
• FP had fewer resuscitation and stabilization
  items than pediatricians (5.7 vs 8.6 items, P
  lt.001)
• FP were less prepared in terms of PALS training
  (19 vs 51, P lt.001).
• Family physicians considered it is less
  important
• Mansfield CJ, Price J, Frush KS, Dallara J.
  Pediatric emergencies in the office are family
  physicians as prepared as pediatricians? J Fam
  Pract. 2001 Sep50(9)757-61

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Lack of Equipment

• Ambulances
• General emergency departments
• Offices

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Improvement - Equipment

• Pediatric Office Emergencies and Emergency
  Preparedness in a Small Rural State
• Barry W. Heath, Jean S. Coffey, Patrick Malone
  and James Courtney
• Pediatrics 20001061391-1396
• http//www.pediatrics.org/cgi/content/full/106/6/1
  391
• 1 event per office in year of study

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Need for Improvement of Knowledge

• Thompson BM, Rice T, Jaffe J, Aprahamian C,
  Horwitz L, Torphy D. "PALS for life!" A
  required trauma-oriented pediatric advanced life
  support course for pediatric and emergency
  medicine housestaff. Ann Emerg Med. 1984
  Nov13(11)1044-7.

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Improvement - Equipment

• Those with PALS training more likely to have
  intraosseous needle
• Braselow tape
• conducted a mock code.
• Mansfield CJ, Price J, Frush KS, Dallara J.
  Pediatric emergencies in the office are family
  physicians as prepared as pediatricians? J Fam
  Pract. 2001 Sep50(9)757-61

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Teaching Helps

• Telephone survey of 94 resident paediatricians in
  England.
• Adherence to guidelines in clinical scenarios
• There were significantly more correct answers to
  9/10 questions in 1999 compared to 1992.
• The 1999 doctors who had attended a course scored
  significantly better in 3/10 questions and
  achieved a higher total score (5.43 versus 4.55).
  
• Carapiet D, Fraser J, Wade A, Buss PW, Bingham R.
  Changes in paediatric resuscitation knowledge
  among doctors. Arch Dis Child. 2001
  May84(5)412-4.

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Teaching Helps?

• Course to pediatric residents at CHOP
• Standardized test from PALS
• Short answer test on clinical problem-solving
  skills.
• Skills workshop
• High scores on the PALS test (93.2/-5.5)
• Less well on short answers (60.0/-9.9)
• No resident was able to successfully perform both
  basic and advanced airway skills,
• Only 11 successfully completed both vascular
  skills
• Nadel FM, Lavelle JM, Fein JA, Giardino AP,
  Decker JM, Durbin DR. Assessing pediatric senior
  residents' training in resuscitation fund of
  knowledge, technical skills, and perception of
  confidence. Pediatr Emerg Care. 2000
  Apr16(2)73-6

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Pediatric Advanced Life Support Course - PALS
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How Sick?
How Quick?
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Pediatric Assessment Triangle
Work of Breathing
Appearance
Circulation to Skin
The Triangle is a rapid way to determine
physiologic stability
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APLS vs PALS

• AAP and ACEP
• Advance Pediatric Life Support The Pediatric
  Emergency Medicine Course Recognize the ill
  child before he is critical

• AHA
• Pediatric Advanced Life Support Primarily
  Resuscitation of the Critically Ill Child

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2005 Resuscitation Guidelines

• http//circ.ahajournals.org/cgi/content/full/112/2
  4_suppl/IV-167
• In contrast to adults, sudden cardiac arrest in
  children is uncommon, and cardiac arrest does not
  usually result from a primary cardiac cause

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Does knowledge last?

• Comparison test scores for the same group of
  trainees (mean training 3 years) at time
  intervals after the course.
• Prior to the course, few of the 23 candidates had
  adequate knowledge of
• cervical spine management (17)
• fluid resuscitation in meningococcal septicemia
  (52)
• shock dose in ventricular fibrillation (61)
• management of anaphylactic shock (35).
• There was a significant improvement in the
  knowledge of the group after the course, with
  median test scores increasing from 19 to a
  maximum of 22 (P lt 0.001).
• This knowledge was retained at 4 months after the
  course
• Durojaiye L, O'Meara M Improvement in
  resuscitation knowledge after a one-day
  paediatric life-support course. J Paediatr Child
  Health. 2002 Jun38(3)241-5.

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APLS - Netherlands

• Questionnaires after course and to control group
• Perceived self-efficacy increased (plt0.01) in
  candidates for all skills and remained increased
  for at least 6 months.
• Turner NM, Dierselhuis MP, Draaisma JM, ten Cate
  OT The effect of the Advanced Paediatric Life
  Support course on perceived self-efficacy and use
  of resuscitation skills. Resuscitation. 2007
  Jun73(3)430-6.

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Israeli Experience

• 128 physicians, 158 nurses, and 84 paramedics.
• Passing 85.9 for physicians, 78.5 for nurses,
  and 89.3 for paramedics.
• The pediatric advanced life support course
  significantly increases immediate short-term
  knowledge of pediatric resuscitation for all
  professional groups.
• Waisman Y, Amir L, Mimouni M.. Does the pediatric
  advanced life support course improve knowledge of
  pediatric resuscitation? Pediatr Emerg Care. 2002
  Jun18(3)168-70

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Israeli Experience

• BACKGROUND The Pediatric Advanced Life Support
  course of the American Heart Association/American
  Academy of Pediatrics was established in Israel
  in 1994 and has since been presented to over
  3,108 medical and paramedical personnel.
• Waisman Y, Amir L, Mor M, Mimouni M. Pediatric
  advanced life support (PALS) courses in Israel
  ten years of experience. Isr Med Assoc J. 2005
  Oct7(10)639-42

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• Paramedics 16 points less after 2 years
• Most still passed
• However, see 3-4 patients per month
• Wolfram RW, Warren CM, Doyle CR, Kerns R, Frye S.
  Retention of Pediatric Advanced Life Support
  (PALS) course concepts. J Emerg Med. 2003
  Nov25(4)475-9

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Course is not enough

• PALS is successful in providing basic
  resuscitation knowledge to pediatric residents,
  is not sustained.
• The course does not provide for the expected
  level of competency in relevant technical skills.
  
• These findings support the hypothesis that the
  PALS course alone is insufficient to provide
  pediatric residents with competency in
  cardiopulmonary resuscitation.
• Grant EC, Marczinski CA, Menon K. Using Pediatric
  Advanced Life Support in pediatric residency
  training Does the curriculum need resuscitation?
  Pediatr Crit Care Med. 2007 Jul 31

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Need Continued Practice

• Resuscitation course 3 practice mock
  resuscitations
• The intervention group scored better on the short
  answer test (Plt.001).
• A larger number of IG were successful in
• ancillary airway maneuvers (P .02)
• femoral vascular access (P .02)
• endotracheal intubation (P .004)
• intraosseous access (P .002)
• Nadel FM, Lavelle JM, Fein JA, Giardino AP,
  Decker JM, Durbin DR. Teaching resuscitation to
  pediatric residents the effects of an
  intervention. Arch Pediatr Adolesc Med. 2000
  Oct154(10)1049-54

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Need Practice

• The results of this study support the
  recommendation that mock codes should be
  performed in the pediatric primary care setting
  to improve practitioner confidence and decrease
  practitioner anxiety
• Toback SL, Fiedor M, Kilpela B, Reis EC. Impact
  of a pediatric primary care office-based mock
  code program on physician and staff confidence to
  perform life-saving skills. Pediatr Emerg Care.
  2006 Jun22(6)415-22.

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Not Taking Course

• Majority of PALS students not physicians.
• Pediatricians in general office practice
  accounted small percentage of participants
• Further research should be conducted to determine
  attitudes toward PALS training and the barriers
  that exist to the office-based pediatrician
  participating in PALS training.
• van Amerongen R, Klig S, Cunningham F Jr,
  Sylvester L, Silber S. Pediatric advanced life
  support training of pediatricians in New Jersey
  cause for concern? Pediatr Emerg Care. 2000
  Feb16(1)13-7

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TEREM APLS COURSE

• Deena R Zimmerman MD MPH
• Course Director
• Nahum Kovalski MD
• Audiovisual Director
• Fred Carol MD
• Equipment Director
• Instructors
• Next course Dec 18/19 2007
• For more information contact dl_at_terem.com

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Day One

• Approach to the critically ill child
• CPR and arrhythmias
• Respiratory emergencies
• Trauma
• Airway skills
• Cardiovascular skills
• IV access
• Wound Management

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Day Two

• Surgical emergencies
• Environmental emergencies
• Fever and (Medical emergencies)
• Radiology
• CNS emergencies
• Toxicology
• Mock Codes
• Written test

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