The task:
In-depth lecture covering Hemodynamic Monitoring of the Critically Ill Patient as well as Respiratory Support and Mechanical Ventilation Strategies.

The audience:
PGY-2 Anesthesiology residents.

The time allotted:
90 minutes.

My response: ARE YOU SERIOUS??

I had to figure out a way to provide a thorough, relevant, topic review of two of the most broad subjects within critical care to residents who were very early in their training and all within a relatively “brief” amount of time. Most importantly, the presentation had to be interesting enough for it not to seem overwhelming so I didn’t lose them halfway through. I shuddered to think how they would feel at the end if I hit them with a bullet rich powerpoint presentation reminiscent of my college and medical school days..Arrrghhhh! (truly Death by Powerpoint).

I needed something that can make them see the BIG PICTURE and not get lost in the details! I have always been a visual learner and I find that drawing my notes, sketching the connections and relationships among things really helped me understand complex topics. I needed a tool that would allow me to teach the way that I like to learn. This is where I found Prezi. Prezi is is a web-based presentation application and storytelling tool that uses a single canvas instead of traditional slides. Instead of presenting slides and bullets, the presenter can zoom in and out as well as pan across the canvas to visually present ideas. It allows the presenter to zoom out to show the big idea and the connections among things and when needed zoom back in to go over the details. Certainly, this is a visual experience much different than a traditional powerpoint presentation. This tool seemed like a perfect fit for me — so I gave it a shot. I recently posted these presentations to the site and they can be seen by clicking on the links below:

1. Hemodynamic Monitoring
2. Mechanical Ventilation

Positive impressions:

• very easy to sign up (used an educator account to signup which took a few minutes
• all the editing was done in a browser which made the whole process very portable. I used chrome and firefox without issues
• very easy to edit, create, embed images and create paths to fly around the screen
• **really made my presentation look and feel like the overview sketch I had created on a piece of paper to show the interactions / connections among topics**
• autosave and undo features are great!
• the file is saved on the prezi servers and anyone can access it — i could control it to be private or shared (needs to be shared to post on blog)
• i could download to my MAC (or a PC) to run as a standalone presentation — this was great for backup in case the website or my internet access was down — i found this a faster way to run the presentation since it relied on the speed of my Mac as opposed to the internet —i can see this being important for LARGE prezis
• presenting was as easy as powerpoint — used the arrow keys to move forward and back — also at any time I could manually control the prezi by using the mouse to zoom in /out and pan around — this was great in case of questions if I needed to go back to a specific point
• i was able to easily embed the prezi in this blog using the simple embed code
• definitely an overall coolness factor to the presentation

Negative impressions:

• I wonder if any of my audience members felt a bit “sea-sick” from the constant panning — there were a couple of times when i wanted to skip a section and clicked through it quite fast. This resulted in a rapid pan-zoom-pan-zoom that even i was uncomfortable with. I had no specific complaints afterwards fromt he audience but I think the presenters have to keep this in mind — what that means is allow the audience to adjust to a motion before moving to the next one. Talk a little slower and move from “slide” to “slide” a little slower
• The path tool which describes how the presentation moves along took a little tweaking – also I found it a bit confusing to go back to the path and change it around. In fact I had to trash the whole path a couple of times. Fortunately, its a pretty quick process so this didn’t add too much to the production time.
• AUDIO!!! this is going to be a big issue for all presenters who would like to make presentations available for viewing on a blog — a lot of us would like the ability to add audio to the presentation that essentially makes this a “prezi-cast” so that viewers online can follow along. Prezi does not make this easy. It only accepts flv/swf audio and adding it to the presentation is not the easiest thing since it has to be individually added in segments as it relates to a step in the path. Even explaining it is difficult for me. Other tools like slideshare make slidecasting very easy allowing presenters to easily add an mp3 file and add timing to it to correlate with the slides. Prezi is definitely behind the eight-ball here and needs to fix this issue.

Overall, I think Prezi is an excellent tool for medical education and it can definitely be used to turn linear (PPT) presentations into a non-linear (canvas like) format which can be visually appealing and allow the audience to really understand the BIG PICTURE first and then focus on the intimate details of the topic. Please watch my presentations and let me know what you think — would you use it to teach complex medical topics?

iPad hands on review: Fits in your white coat and is fast enough for Medical point of care use [Healthcare Perspective]

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It really starts with you. As taboo as the topic may be, its a must for every individual to think about this and most importantly discuss it with the ones you love most. This is the most effective way to ensure that your wishes are truly upheld.

Here’s a great tool available online – The One Slide Project

Here is a link to the US Living Will Registry where you can find out more specific information. The link takes you directly to the state specific forms.

Several measures of ICU performance have been proposed in the past 30 years. It is intuitive, and correct, to assume that ICU mortality may be a useful marker of quality. However, crude mortality rates does not take into consideration the singular aspects of each specific patient population that is treated in a certain geographic region, hospital or ICU. Therefore approaches looking for standardized mortality ratios that are adjusted for disease severity, comorbidities and other clinical aspects are often sought. Severity of illness is usually evaluated by scoring systems that integrates clinical, physiologic and demographic variables. Scoring systems are interesting tools to describe ICU populations and explain their different outcomes. The most frequently used are the APACHE II, SAPS II and MPM. However, newer scores as APACHE IV and SAPS III have been recently introduced in clinical practice. More than only using scoring systems, one should search for a high rate of adherence to clinically effective interventions. Adherence to interventions as deep venous thrombosis prophylaxis, reduction of ICU-acquired infections, adequate sedation regimens and decreasing and reporting serious adverse events are essential and have been accepted as benchmarking of quality.

The complex task of collecting and analyzing data on performance measures are made easier when clinical information systems are available. Although several clinical information systems focus on important aspects as computerized physician order entry systems and individual patient tracking information, few have attempted to gather clinical information generating full reports that provide a panorama of the ICU performance and detailed data on several domains as mortality, length of stay, severity of illness, clinical scores, nosocomial infections, adverse events and adherence to good clinical practice. Through implementing quality initiatives, increasing the quality of care and patient safety are major and feasible goals. Such systems are available for clinical use and may facilitate the process of care on a daily basis and provide data for an in-depth analysis of ICU performance.

FDA’s anesthesiology and respiratory therapy devices advisory committee will meet May 28 in Gaithersburg, Md., to discuss Johnson & Johnson/Ethicon Endo-Surgery’s pre-market approval application for its Sedasys computer-assisted personalized sedation system, indicated for minimal to moderate sedation in adult patients undergoing colonoscopy and esophagogastroduodenoscopy procedures.

This is certainly going to spark some fireworks on both sides of the court. Can this really replace anesthesiologist presence in the GI suite? Lets see what the FDA has to say. In my opinion, we should certainly not jump to quick legislation and really put patient safety at the forefront! Just because it can be done DOESN’T mean it should be done.

Here is information about this controversial and potentially game changing technolology from JnJ.

Ethicon Endo-Surgery announced that the results from its pivotal trial demonstrated physician/nurse teams using the SEDASYS™ System reduced the risk of over sedation with propofol in patients undergoing screening and diagnostic procedures for colorectal cancer (colonoscopy), and disorders of the upper gastrointestinal tract (EGD). The study [...] included 1,000 subjects who underwent sedation for colonoscopy and EGD at eight sites and compared the SEDASYS™ System to the current standard of care for sedation (midazolam plus fentanyl or meperidine). Results were included in Ethicon Endo-Surgery’s PreMarket Application (PMA) for approval of the SEDASYS™ System, which is currently in review with the U.S. Food and Drug Administration.

“During the trial, the system made it possible for gastroenterologists to maintain minimal to moderate sedation with propofol, and helped prevent patients from entering deep sedation, which is traditionally associated with propofol,” said Daniel Pambianco, MD, F.A.C.G., medical director of Charlottesville (Va.) Medical Research and trial investigator. “The system offers a way to personalize the level of sedation appropriate for each patient because it combines propofol delivery with sophisticated monitoring to help us better control and predict the patient’s sedation level.”

Patients who received sedation with the SEDASYS™ System experienced fewer and less significant oxygen desaturation events, a clinical sign of over sedation, than patients sedated with current standard of care. The trial demonstrated this by achieving its primary endpoint of Area Under the Curve (AUC) of oxygen desaturation (SpO2 < 90%). AUC is an objective measure of a patient’s respiratory status that incorporates incidence, duration and depth of oxygen desaturation. Patients in the SEDASYS™ System group had an average AUC value of one-third less than the current standard of care patients. No device-related adverse events occurred in patients sedated with the SEDASYS™ System.

SEDASYS™ System patients were minimally-to-moderately sedated with propofol during the study. Sedation level was assessed every two minutes using a Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scale of 0-5. Patients who are minimally sedated respond readily when called by name (MOAA/S=5), while moderately sedated patients may require mild tactile stimulus to respond (MOAA/S=2-4). More than 99 percent of SEDASYS™ System patient responses were a MOAA/S score of 2 – 5, indicating minimal to moderate sedation.

(excerpt from may 2008 taken from)
Johnson and Johnson
http://www.jnj.com

List of Useful Resources:

American Society of Anesthesiology:

• Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia – 2004
• Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists, 2002
• Granting Privileges for Administration of Moderate Sedation to Practitioners Who Are Not Anesthesia Professionals – 2006
• Granting Privileges to Non-Anesthesiologist Practitioners for Personally Administering Deep Sedation or Supervising Deep Sedation by Individuals Who Are Not Anesthesia Professionals, Statement on — 2006

Ohio Board of Nursing

• State of Ohio Board of Nursing: Guidelines for Administration of Medications, and Monitoring of Patients Receiving Intravenous Moderate Sedation for Medical/Surgical Procedures, July 20, 2007

ACG (American College of Gastroenterology) Practice Guidelines

• ACG Practice Guidelines

ASGE (American Society for Gastrointestinal Endoscopy) Practice Guidelines

• ASGE Practice Guidelines

Her is a presentation that goes over what my vision is for the “FUTURE ICU.” I originally presented this about a year ago during my fellowship. Enjoy!