e2 47 Kanter RK Regional variation in critical care evacuation needs for children after a mass casualty incident Disaster Med Public Health Prep 2012;6(2) 146 149 48 Foltin GL, Schonfeld DJ, Shannon M[.]
e2 47 Kanter RK Regional variation in critical care evacuation needs for children after a mass casualty incident Disaster Med Public Health Prep 2012;6(2):146-149 48 Foltin GL, Schonfeld DJ, Shannon MW Pediatric Terrorism and Disaster Preparedness: A Resource for Pediatricians Rockville, MD: Agency for Healthcare Research and Quality (AHRQ publication No 06-0056-EF); 2006 49 Powell T, Christ KC, Birkhead GS Allocation of ventilators in a public health disaster Disaster Med Public Health Prep 2008;2:20-26 50 Ely DM, Driscoll AK, Mathews TJ Infant Mortality By Age at Death in the United States, 2016 NCHS Data Brief, no 326 Hyattsville, MD: National Center for Health Statistics; 2018 51 Christian MD, Sprung CL, King MA, et al Triage: care of the critically ill and injured during pandemics and disasters: chest consensus statement Chest 2014;146(suppl 4):e61S-e74S 52 Kanter RK Would triage predictors perform better than first-come, first-served in pandemic ventilator allocation? Chest 2015;147(1): 102-108 53 Johnson EM, Diekema DS, Lewis-Newby M, et al Pediatric triage and allocation of critical care resources during disaster: northwest provider opinion Prehosp Disaster Med 2014;29(5): 455-460 54 Schreiber M The psySTART Rapid Mental Health Triage and Incident Management System Center for Disaster Medical Sciences, University of California; 2010 55 Eriksson, CA, Foy, DW, Larson, LC: When the helpers need help: early intervention for emergency and relief services personnel In: Litz BT, ed Early Intervention for Trauma and Traumatic Loss New York: Guilford Press; 2004:241-262 e3 Abstract: During a public health emergency (PHE) such as a natural disaster or pandemic, a large number of infants, children, and young adults may need critical care in order to survive During such an event, the incident command system provides a framework to support decision-making and coordinate efforts across affected sites Because pediatric critical care is highly specialized and because few nonpediatric providers are comfortable caring for severely ill or injured children, pediatric, neonatal, and cardiac intensive care units represent an essential aspect of patient management during a PHE and should be included within a structured response Key words: Emergency mass critical care, EMCC, public health emergency, PHE, natural disaster, pandemic 10 Lifelong Learning in Pediatric Critical Care STEPHANIE P SCHWARTZ, LAURA MARIE IBSEN, AND DAVID A TURNER • • Pediatric critical care medicine (PCCM) is a discipline dedicated to the care of the critically ill child, focusing on the sick child as a whole and including the impact of disease on all organ systems In addition, pediatric intensivists must address and understand the physical, mental, and emotional needs of the child and the child’s family The complex needs of the critically ill child also require that intensivists be prepared to assume a leadership role in the coordination of care among team members from multiple disciplines The pediatric intensivist must develop an understanding of the ethics of critical care medicine and be able to balance complex and high-technology care with humanistic principles and respect for the patient as a human being The intensivist must be knowledgeable in patient safety and quality improvement methodology and lead these efforts in the intensive care unit (ICU) environment Skills for evaluating medical literature, clinical and/or basic science research, and the ability to teach learners at different levels and from a variety of disciplines effectively are also invaluable Development of this complex array of knowledge and skills begins in medical school, with the goal of mastery over the course of an individual’s career Becoming a master in the specialty of pediatric critical care hinges on lifelong learning, which implies that the described individual has a voluntary interest in self-development and learning for the sake of learning This enjoyment associated with learning is thought to be moldable and 66 • The practice of pediatric critical care medicine requires a broad knowledge base and skill set that necessitates lifelong learning throughout an intensivist’s career to achieve mastery Based on adult learning principles, education efforts should emphasize active participation and practice, examples of which include bedside teaching, procedural training, debriefing, and simulation Training in critical care medicine should reflect a structured process that progressively transfers increasing levels of responsibility for decision-making to the learner Entrustable professional activities describe an ability to perform a task or responsibility without direct supervision once • • • PEARLS sufficient competency is attained Milestones provide behavioral descriptors that indicate developmental progression along competencies Continuing medical education and maintenance of certification programs are working together to incorporate adult learning principles The mature clinician reflects on one’s daily medical experiences to place them in a larger context of previous encounters and critically evaluates one’s own performance, acknowledging both effective and ineffective aspects of patient care able to be influenced, even developed and promoted through the use of adult learning principles Adult Learning Theory in Medical Education Adult learning theory was theorized and modeled by Malcom Knowles in the 1970s.1 He identified six principles of adult learning (Box 10.1) Knowles drew on the work of Kolb,2 using these principles to emphasize that there is not a one-size-fits-all approach to learning For example, the reader might imagine two individuals who purchase a new electronic device Whereas one may take the device out of the box, immediately turn it on, and begin experimenting with its features, the other purchaser may not even remove it from the box before reading the entire instruction manual Adult learning theory celebrates the differences in the approach to learning while making these differences overt and explicit In designing and implementing curricula and assessments, medical educators may design curricula and evaluations that use these concepts Kolb described effective learning as a progression through a cycle of stages— having a concrete experience, followed by reflection on that experience, leading to information synthesis and future testable hypotheses For those familiar with quality improvement principles, it is not unlike plan-do-study-act,3 in which small tests CHAPTER 10 Lifelong Learning in Pediatric Critical Care • BOX 10.1 Knowles Principles of Adult Learning Adults are: • internally motivated and self-directed • goal oriented • relevancy oriented • practical Adults bring life experiences and knowledge of learning experiences Adult learners like to be respected of change are implemented, observed, and the necessary modifications determined Building on these principles, a key element of medical education is to use learner assessment to drive teaching methods Stuart and Hubert Dreyfus developed a model of skill acquisition based on their studies of fighter pilots.4 The Dreyfus 67 model proposes that skill acquisition is not different from the continuum of human development, with stages of skill acquisition designated as novice, advanced beginner, competent, proficient, expert, and—finally—master The learner needs to acquire certain skills and learn certain concepts at each level; therefore teaching methods have to match the level of development (Table 10.1).5 Adult learning is fundamentally different from childhood learning because of the greater depth and breadth of experiences and knowledge on which adults build new experiences.6,7 In order to assimilate new information, adults must be able to integrate new ideas with what they already know, and information that conflicts with this knowledge may not be quickly integrated.8 Adults are self-directed and autonomous They learn best when they are active participants in the learning process and are allowed to practice newly acquired skills and concepts.7,9 As a consequence, education for adults is typically most effective when TABLE Dreyfus and Dreyfus Model of Skill Development Applied to the Development of a Competence in the 10.1 Subspecialty of Critical Care Medicine Level of Learning and Characteristics Examples of Learner Level in Critical Care Medicine Teaching Implications Teach basic critical care concepts Point out subtle but meaningful diagnostic information in the history and physical examination Eliminate irrelevant information Highlight discriminating features and their importance to the diagnosis Encourage reading about diagnostic hypotheses at the same time Novice First-Year Fellow Rule driven Uses analytical reasoning and rules to link cause and effect Synthesis of information is based on knowledge acquired during residency training Big picture elusive Interviews patient and performs a physical exam that is focused on the critical illness May not be able to focus the information on the basis of a differential diagnosis Does not see the big picture Advanced Beginner Second-Year Fellow Sorts through rules and information to decide what is relevant on the basis of past experience Uses analytical reasoning and pattern recognition to solve problems Able to abstract from concrete and specific information to more general aspects of a problem Expose learner to clinical cases proceeding from common to uncommon Can generate more specific differential diagnosis Emphasize the use of semantic qualifiers while obtaining history and physical exam Encourage formulation and verbalization of Capable of filtering relevant information to fordifferential diagnosis and treatment plan mulate a unified summary of the case Good coaching: help learner become attentive to Can abstract pertinent positives and negatives the meaningful pieces from the review of systems and incorporate them into the history of present illness Competent Third-Year Fellow Emotional buy-in allows learner to feel appropriate level of responsibility More expansive experience tips the balance on clinical reasoning from methodical and analytic to identifiable pattern recognition of common clinical problems Sees the big picture Complex/uncommon problems still require reliance on analytical reasoning Balance supervision with autonomy in decisionmaking Recognizes common patterns of illness based on Hold learners accountable for their decisions previous encounters Do not tell learners what to do; ask what they want Sees consequences of clinical decisions, which to leads to emotional buy-in to learning Critical for learner to see a breadth and depth of Will methodically attempt to reason through patient encounters to construct and store in complex or uncommon problems memory a large repertoire of illness scripts Responsible for decision-making process Tip the balance from clinical reasoning to pattern recognition Proficient Clinical Instructor Breadth of past experience allows reliance on pattern recognition of illness Problem solving intuitive Still needs to fall back to methodical and analytic reasoning for managing problems because exhaustive number of permutations and responses to management have provided less experience in this regard than in illness recognition Is comfortable with evolving situations, able to extrapolate from a known situation to an unknown situation Can live with ambiguity Starts to match findings with those encountered in past experience Data gathering more effective and efficient Sees patient through different lens than the student Engages in process of clinical reasoning to find the best intervention Needs to work alongside and be mentored by an expert Must develop capacity to know ones’ limitations and step back and call on additional resources when stretched beyond one’s capabilities 68 S E C T I O N I Pediatirc Critical Care: The Discipline TABLE Dreyfus and Dreyfus Model of Skill Development Applied to the Development of a Competence in the 10.1 Subspecialty of Critical Care Medicine—cont’d Level of Learning and Characteristics Examples of Learner Level in Critical Care Medicine Expert Assistant Professor Thought, feeling, and action align into intuitive problem recognition and intuitive situational responses and management Open to noticing the unexpected Clever Discriminates features that not fit a recognizable pattern Teaching Implications Keep up the challenge Broad repertoire of illness scripts, based on clini- Needs ongoing experience and ongoing exposure to interesting and complex cases to avoid complacal experience that allows immediate action cency and to help transcend beyond this level for majority of clinical encounters Should be apprenticed to a master who models the Likes to deal with diagnostic dilemmas skills of the reflective practitioner and a comWhen presented with diagnostic dilemma, will mitment to lifelong learning slow down and look it up Master Associate Professor/Professor Exercises practical wisdom Goes beyond the big picture to that of culture and context of each situation Deep level of commitment to the work Great concern for right and wrong decisions that fosters emotional engagement Intensely motivated by emotional engagement to pursue ongoing learning and improvement Reflects in, on, and for action The clinician that everyone goes to with problem cases Recognizes subtle features of a current case reminiscent of cases seen over the years Painstakingly revisits past cases or identifies common thread that will help treat the current clinical problem Vision extends beyond individual practice Contributes to bigger context to improvements in the field Intense internal drive to learn and improve Practical wisdom Self-motivated to engage in lifelong learning and practice improvement Modified from Carraccio CL, Benson BJ, Nixon LJ, Derstine PL From the educational bench to the clinical bedside: Translating the Dreyfus developmental model to the learning of clinical skills Acad Med 2008;83(8):761–767 programs facilitate self-learning with specific goals of acquiring practical information Efforts to be inclusive of curricular methods that support adult learning principles are occurring in undergraduate, graduate, and continuing medical education Problem-based and small-group learning, flipped classrooms, and simulation exercises allow many venues for reaching learners in different ways Didactic learning remains firmly in place It should be emphasized that no one method of instruction has been definitively proven to produce better learning outcomes than another.9–11 Table 10.2 depicts varied instructional techniques with potential benefits and costs If assessment truly drives learning, medical educational curricula must be increasingly grounded in the assessment of knowledge and skills acquisition, now defined as abilities (or entrustable professional activities) and composed of individual competencies For example, one could consider a teenager first learning to drive a car The teenager must be competent in many individual areas, such as knowledge of the laws of the road and the skills of braking, using turn signals, mirrors, and seatbelts before embarking on this activity and being entrusted to drive the car Like supervising a learner performing a technical procedure on a critically ill child, the trust that a parent affords a child in independent driving is fluid The teenager may initially receive parental permission for driving around the neighborhood When demonstrating responsible and safe driving conduct, the teenager may gain parental trust to drive on the freeway or with friends Likewise, the graduated autonomy that a supervising intensivist will allow learners in performing central line placement will vary according to individual knowledge and skills, but it is also highly contextual As is reflected in the 2004 guidelines for critical care medicine training and continuing medical edition published by the Society for Critical Care Medicine, training in critical care medicine should reflect a structured process that progressively transfers increasing levels of responsibility for decision-making and that ensures continued training in practical aspects of care.12 Graduate Medical Education The landscape of graduate medical education (GME) has dramatically evolved since its apprenticeship/house officer origins in the early 1900s In the past decade, increasing scrutiny has been placed on GME, with a specific focus on duty hours In 2011 the Accreditation Council for Graduate Medical Education (ACGME) placed restrictions on duty hours in an effort to increase safety for patients and learners based on some data to suggest that sleep deprivation and fatigue causes errors, and that alertness and performance vary within different points in the circadian rhythm.13–15 These restrictions undeniably changed the landscape of learning For example, duty hour regulations led to an increase in the number of times that care of a patient was transferred to a different provider, which prompted educational reform around transitions of care with programs such as I-PASS (illness severity, patient summary, action list, situational awareness, and synthesis by receiver).16 Following two large randomized control trials showing noninferiority with regard to patient outcomes and resident satisfaction or well-being,17,18 the ACGME issued revised guidelines in 2017, allowing for more flexibility with regard to duty hours and, most importantly, stressing the importance of teamwork, physician well-being, flexibility, and patient safety.19 Along with changes in expectations around hours worked, expectations for GME programs have also evolved to focus more on patient safety, quality, and teamwork, along with the traditional specialty- and subspecialty-specific content that is important for new physicians ... units represent an essential aspect of patient management during a PHE and should be included within a structured response Key words: Emergency mass critical care, EMCC, public health emergency,... members from multiple disciplines The pediatric intensivist must develop an understanding of the ethics of critical care medicine and be able to balance complex and high-technology care with humanistic... different levels and from a variety of disciplines effectively are also invaluable Development of this complex array of knowledge and skills begins in medical school, with the goal of mastery over