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ABCDE approach to victims by lifeguards: how do they manage a critical patient? A cross sectional simulation study

Authors:
Felipe Fernández-Méndez at University of Vigo
Felipe Fernández-Méndez
Martín Otero-Agra at University of Vigo
Martín Otero-Agra
Cristian Abelairas-Gómez at University of Santiago de Compostela
Cristian Abelairas-Gómez
Nieves Saez at University of Castilla-La Mancha
Nieves Saez
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Abstract

Introduction: Decision-making in emergencies is a multifactorial process based on the rescuer, patient, setting and resources. The eye-tracking system is a proven method for assessing decision-making process that has been used in different fields of science. Our aim was to evaluate the lifeguards' capacity to perform the ABCDE (Airway-Breathing-Circulation-Dissability-Exposure) approach when facing a simulated critically ill-drowned victim. Methods: A cross sectional simulation study was designed to assess the skills and sequence of the ABCDE approach by 20 professional lifeguards. They had to assess a victim and act according to his/her clinical status following the ABCDE primary assessment approach. Two kind of variables were recorder: those related to quality of each step of the ABCDE approach; visual behaviour using a portable eye-movement system. The eye-tracking system was the Mobile Eye system (Bedford, USA). Results: None of the study participants was able to complete correctly the ABCDE approach. Lifeguards spent more time in the Circulation step: Airway (15.5±11.1 s), Breathing (25.1±21.1 s), Circulation (44.6±29.5 s), Disability (38.5±0.7 s). Participants spent more time in viewpoints considered as important (65.5±17.4 s) compared with secondary ones (34.6±17.4 s, p = 0.008). This also was represented in the percentage of visual fixations (fixations in important viewpoints: 63.36±15.06; fixation in secondary viewpoints: 36.64±15.06). Conclusion: Professional lifeguards failed to fully perform the ABCDE sequence. Evaluation by experts with the help of eye-tracking technology detected lifeguards' limitations in the assessment and treatment of an eventual critically ill victim. Such deficits should be considered in the design and implementation of lifeguards’ training programmes.
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1
ABCDE approach to victims by lifeguards: how do they manage a critical patient? A
cross sectional simulation study
Felipe Fernández-Méndez1,2, Martín Otero-Agra3, Cristian Abelairas-Gómez1,4,5,*,
Nieves Maria Saez-Gallego6, Antonio Rodríguez-Núñez, MD1,5,7,8, Roberto Barcala-
Furelos3,5
1CLINURSID Research Group, University of Santiago de Compostela, Santiago de
Compostela, Spain
2University College of Nursing, University of Vigo, Pontevedra, Spain
3Faculty of Education and Sport Sciences, REMOSS Network Research, University of
Vigo, Pontevedra, Spain
4Faculty of Education Sciences, Universidade de Santiago de Compostela, Santiago de
Compostela, Spain
5Institute of Health Research of Santiago (IDIS), Santiago de Compostela, Spain6
6Faculty of Education, University of Castilla la Mancha, Toledo, Spain
7Pediatric Area, Pediatric Emergency and Critical Care Division, University Hospital of
Santiago de Compostela, Santiago de Compostela, Spain
8Mother-Child Health and Development Network (Red SAMID), Carlos III Health
Institute, Madrid, Spain
Corresponding Author
Cristian Abelairas-Gómez
cristianabelairasgomez@gmail.com
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2
1ABCDE approach to victims by lifeguards: how do they manage a critical patient?
2A cross sectional simulation study
3Decision-making in lifesaving
4
5Abstract
6Introduction: Decision-making in emergencies is a multifactorial process based on the
7rescuer, patient, setting and resources. The eye-tracking system is a proven method for
8assessing decision-making process that has been used in different fields of science. Our
9aim was to evaluate the lifeguards' capacity to perform the ABCDE (Airway-Breathing-
10 Circulation-Dissability-Exposure) approach when facing a simulated critically ill-
11 drowned victim.
12 Methods: A cross sectional simulation study was designed to assess the skills and
13 sequence of the ABCDE approach by 20 professional lifeguards. They had to assess a
14 victim and act according to his/her clinical status following the ABCDE primary
15 assessment approach. Two kind of variables were recorder: those related to quality of
16 each step of the ABCDE approach; visual behaviour using a portable eye-movement
17 system. The eye-tracking system was the Mobile Eye system (Bedford, USA).
18 Results: None of the study participants was able to complete correctly the ABCDE
19 approach. Lifeguards spent more time in the Circulation step: Airway (15.5±11.1 s),
20 Breathing (25.1±21.1 s), Circulation (44.6±29.5 s), Disability (38.5±0.7 s). Participants
21 spent more time in viewpoints considered as important (65.5±17.4 s) compared with
22 secondary ones (34.6±17.4 s, p = 0.008). This also was represented in the percentage of
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3
23 visual fixations (fixations in important viewpoints: 63.36±15.06; fixation in secondary
24 viewpoints: 36.64±15.06).
25 Conclusion: Professional lifeguards failed to fully perform the ABCDE sequence.
26 Evaluation by experts with the help of eye-tracking technology detected lifeguards'
27 limitations in the assessment and treatment of an eventual critically ill victim. Such
28 deficits should be considered in the design and implementation of lifeguards’ training
29 programmes.
30 Keywords: Lifeguard; ABCDE approach; decision-making; Trauma.
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31 Introduction
32 Drowning is a public health problem identified by the WHO as one of the main
33 causes of mortality and morbidity [1], and lifeguards are the professionals with the duty
34 to intervene in an aquatic incident. In addition to environmental water risks, the current
35 occupation and use of aquatic environments for leisure is very popular [2], so other
36 medical complications may also require the attention of lifeguards.
37 The actions that lifeguards perform when incidents happen in aquatic
38 environments are defined by the drowning timeline, that includes preparation,
39 prevention, rescue and mitigation [3]. Mitigation refers to the skills for the evaluation
40 and treatment of the victim after an incident.
41 Mitigation of the aquatic incident requires identifying the problem, establishing
42 a preliminary diagnosis and making the appropriate decisions to ease the drowning in a
43 hostile environment [4]. Besides, for each drowned person, it has been estimated that
44 three people receive care in the emergency services [5].
45 Usually, when talking about drowning, collective thinking associates it with the
46 worst scenario, that is the cardiorespiratory arrest for which the European Guidelines for
47 Resuscitation 2015 recommend to perform cardiopulmonary resuscitation [6]. However,
48 the non-fatal drowning that does not necessarily needs a cardiopulmonary resuscitation,
49 but needs alternative urgent attention is much more prevalent [7]. And it is the one that
50 requires an ABCDE approach to assess the signs and symptoms and to offer an
51 adequate immediate treatment [8].
52 Unlike other health professionals, for lifeguards 99% of the actions are focused
53 on prevention and rescue and only 1% belong to the care of critically ill patients [7].
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54 However, lifeguards have to be prepared for when this 1% of critical interventions
55 occur, in which’s the decision-making is essential. The decision-making in emergencies
56 is a multifactorial process based on the rescuer, the patient, the setting and the
57 resources, which is difficult to assess since it is an internal process that occurs rapidly
58 [9].
59 To try to understand this decision-making process, the eye-tracking system was
60 reported as a valid and reliable instrument. It is a proven method that has been used in
61 different fields as sport sciences [10,11] or emergencies [12]. In addition, it is
62 considered a great tool that might positively contribute to improve lifeguards’ skills
63 [13].
64 Therefore, the aim of the study was to evaluate systematically the decision-
65 making and the capacity in the use of the ABCDE approach by lifeguards.
66
67 Methods
68 Sample
69 A convenience sample of 20 professional lifeguards was invited to participate in this
70 study. Participation was voluntary and authorized through written informed consent. All
71 lifeguards were active professionals trained at the University of Vigo (Spain). Their
72 rescue training was in accordance with regional laws and followed the
73 recommendations for resuscitation of the European Resuscitation Council [14].
74
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75 Study design
76 A cross sectional simulation study was design to evaluate the skills and sequence
77 of the ABCDE approach. This study was approved by the Ethics Committee of the
78 Faculty of Education and Sports Sciences (University of Vigo - Spain) with code 04-
79 1812-17.
80
81 Simulating scenario
82 The simulating scenario was designed by a multidisciplinary group of experts
83 (emergency doctors, nurses and first-aid coordinators), all of them simulation specialists
84 and instructors. The manikin simulator was programmed according to the values in table
85 1.
Table 1. Simulator programming.
Airway
Airway obstruction by tongue fall due to decreased level of
consciousness.
Breathing
Respiratory rate of 40 breaths per minute. Superficial breaths.
Circulation
Heart rate of 140 beats per minute. Weak radial pulse and strong carotid
pulse. Blood pressure of 90/60 mmHg.
Disability
The simulator did not respond to verbal stimuli. Facing painful stimuli,
the patient responded with a scream.
Exposure
Wound due to erosion in left lower limb with small haemorrhage
(distracting wound).
86
87 The participants received the indication that they would enter a room in which
88 they should assess a victim and that they should act according to his/her clinical status
89 following the ABCDE primary assessment approach. The room simulated a beach aid
90 station. The usual material to attend the victim in a real case was available. The
91 simulator remained in the same situation, unchanged, for 10 minutes at which time it
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92 went into PCR (see supplementary video). If the participants finished the ABCDE
93 approach before 10 min, the instructor would configure the simulator into cardiac arrest
94 immediately.
95 The subjective evaluation of the lifeguards' performance was carried out by a
96 BLS instructor and two ALS instructors trained under the ERCGL 2015 guidelines
97 [14,15]. To do this, a checklist was used to evaluate the ABCDE primary assessment
98 based on the recommendations of the Prehospital Trauma Life Support [16].
99
100 Variables
101 Demographic data such as sex, age, height, weight and body mass index (BMI)
102 were recorded. Afterwards, variables related to the training of the participants were
103 recorded: last training, knowledge of ABCDE approach, have you ever had to perform
104 of ABCDE approach, knowledge of AED and have you done any simulation practice.
105 Variables regarding to ABCD approach are shown in Table 2. Eye-tracking
106 allowed to collect data of views from the located point were obtained and percentage of
107 time which the located point was viewed from the following areas (defined as
108 viewpoints of great importance): Airway (mouth), Breathing (neck, thorax, abdomen),
109 Circulation (arm, leg, hand, haemorrhage, carotid pulse, radial pulse), Disability (eyes)
110 and Exposure (thermal blanket) and AED.
111
112
113
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Table 2. Capacity to perform the ABCDE approach.
Airway
Asses airway
Observe the inside of the
mouth for foreign bodies
and/or secretion and perform
manoeuvre to open the airway
or use an oropharyngeal
cannula.
Breathing
Assess breathing
Observe if the patient breathes
chest symmetry and presence
of wounds in the thorax.
Circulation
Assess circulation
Observe the presence of
haemorrhage, peripheral and
central pulses.
Disability
Assess disability
Evaluate according to the
AVPU scale.
Exposure
Asses exposure
Cardiac arrest
recognition
Perform CPR
with AED
114
115
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116 Instruments
117 The evaluation was performed on a manikin ALS Simulator (Laerdal, Stavanger,
118 Norway). The gaze fixation variables were obtained through the Mobile Eye gaze
119 tracking system of the ASL laboratories (Bedford, USA). It is based on lightweight
120 glasses that support two cameras: one of them records the scene and the other the point
121 where the vision is focused (extracted by the reflection produced by the cornea and the
122 pupil in a lens). Both signals are registered through its DVCR recording unit and
123 integrated into one via the computer system. This gives us a joint view of the
124 environment observed by the participant and the visual fixations performed. The Mobile
125 Eye system was calibrated using the Eye Vision 2.2.5 software. The resulting videos
126 (supplementary file) have been analysed using the ASL Result Plus Gaze Map software.
127 Both installed in the ACER ASPIRE 5920G laptop (Make INC, Taipei, Taiwan).
128
129 Statistical analysis
130 The statistical analysis was performed with the Windows statistical package
131 IBM SPSS Statistics version 20 (SPSS, Chicago, Illinois, USA). Continuous variables
132 were described according to measures of central tendency (mean) and dispersion
133 (standard deviation). Categorical variables were described according to absolute and
134 relative frequencies. To verify the normality of the sample, the Kolmogorov-Smirnov
135 test was performed. The Wilcoxon Signed Rank Test was used to verify the differences
136 between the viewpoints of great importance in the ABCDE approach and the
137 unimportant ones, and also to find differences between the percentage of fixations and
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138 the percentage of fixation time at each point (significance level of p < 0.05 in both
139 analyses).
140
141 Results
142 Characteristics of participants.
143 A total of 18 men and 2 women participated in the study with age of 28.35±6.90 years
144 old, weight of 73.30±8.39 kg, height of 176.40±6.58 cm and BMI of 23.51 ± 2.04 kg·m-
145 2.
146 As for the training of the participants, their last formal training was 31.40±35.40 months
147 before the study. Half of the participants received their last accredited training in a
148 period of 1 year prior to the study. All participants knew what the ABCDE approach
149 was, although 55% had not used it nor had previously performed a simulation scenario
150 test.
151
152 ABCDE approach
153 None of the study participants managed to complete the primary assessment correctly.
154 Regarding the results of the assessment parts (Fig 1):
155 Airway: 45% of the participants performed the airway approach as the first step. 30% of
156 the participants did not take this step and half did it incorrectly.
157 Breathing: This part of the primary assessment was carried out by 55% of the
158 participants in second place, and 15% did not contemplate it. 25% of the participants
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159 correctly assessed breathing. 80% checked the victim's breathing and 30% checked the
160 symmetries of the victim's thorax.
161 Circulation: 60% of the participants assessed the circulation, but none did it correctly
162 and less than half did it in third place (40%). The majority of the participants did not
163 check pulses, and 35% did not perform the assessment of potential haemorrhages.
164 Disability: Only two participants evaluated this step, one in second and another in
165 fourth place.
166 Exposure: 25% of the participants performed this step.
167 Cardiac arrest recognition and performance: Half of the participants knew how to
168 recognize the cardiac arrest at the time it took place, but only 35% of the participants
169 used an AED together with CPR.
170 << Insert Figure 1 near here >>
171
172 Fixations during ABCDE approach (Eye-Tracking)
173 Data from 4 lifeguards has been lost due to technical issues. No significant differences
174 were observed in any of the vision points when comparing the percentage of fixations
175 and the percentage of fixation time (p > 0.05).
176 Table 3 and Table 4 show the total percentage of fixings of the most important
177 viewpoints comparing with the unimportant. In addition, the percentage of fixings of
178 each important viewpoint with respect to the total. Regarding to time, time spend in
179 each viewpoint is expressed in percentage and the time spend in each part of the
180 ABCDE approach is shown in seconds.
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181 Around 60% of the fixations and fixation time were devoted to important areas of vision
182 for the ABCDE approach (Fig 2), with significant differences being found when
183 compared with unimportant vision areas (p < 0.008).
184 The "Circulation" approach was the one that required more time to carry out its
185 assessment (44.6 s), followed by "Disability" (38.5 s) and "Breathing" (25.1 s). The
186 steps that required less time were "Exposure" (3.8 s) and "Airway" (15.5±11.1 s).
187 Airway: A 17.58% of fixations was required to assess the mouth-airway.
188 Breathing: The assessment of the thorax was the stage that required the highest
189 percentage of fixations on the total number of fixations (9.73%). The assessment of the
190 neck was the one with the lowest percentages (4.03%). The assessment of the abdomen
191 shows a fixation percentage of 5.81%.
192 Circulation: The assessment of bleeding was the one that required the highest fixation
193 percentages (6.99%), followed by the arm (6.69%). The assessment of the legs obtained
194 percentages of 4.06%, while the evaluation of the hand, carotid pulse and radial pulse
195 obtained percentages lower than 2%.
196 Disability: The eye assessment obtained fixation percentages of 0.93%.
197 Exposure: The thermal blanket obtained higher percentages (4.15%).
198
199
200
201
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Table 3. Descriptive analysis about fixings performed by participants during ABCDE approach (Total,
Airway and Breathing).
N = 16 (4 lost)
Mean (SD)
CI
Wilcoxon Signed Rank Test
Fixings (%)
63.36 (15.06)
55.34-71.39
Viewpoints of great
importance
Time (%)
65.45 (17.36)
56.20-74.70
Fixings (%)
36.64 (15.06)
28.61-44.66
Unimportant
viewpoint
Time (%)
34.55 (17.36)
25.30-43.80
Total significantly point-views
vs.
Total insignificantly point-views
(p = 0.008)
Airway
Fixings (%)
17.58 (9.78)
12.37-22.79
Mouth
Time (%)
18.16 (11.11)
12.24-24.08
Time in Airway (s)
15.50 (9.17)
10.20-20.80
Breathing
Fixings (%)
4.03 (3.43)
2.20-5.86
Neck
Time (%)
4.87 (5.43)
1.98-7.76
Fixings (%)
5.81 (3.32)
4.03-7.58
Abdomen
Time (%)
7.72 (7.93)
3.50-11.95
Fixings (%)
9.73 (6.98)
6.01-13.44
Thorax
Time (%)
9.80 (8.47)
5.29-14.32
Time in Breathing (s)
25.12 (21.12)
14.26-35.98
Fixings and time of total and each viewpoint in percentage.
Time of each total section of ABCDE approach in seconds.
202
203
204
205
206
207
208
209
210
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Table 4. Descriptive analysis about fixings performed by lifeguards during ABCDE
approach (Circulation, Disability, Exposure and AED).
N = 16 (4 lost)
Mean (SD)
CI
Circulation
Fixings (%)
1.40 (1.79)
0.45-2.35
Hand
Time (%)
1.93 (2.72)
0.48-3.38
Fixings (%)
6.69 (5.76)
3.61-9.76
Arm
Time (%)
5.98 (7.40)
2.03-9.92
Fixings (%)
4.06 (5.63)
1.06-7.06
Leg
Time (%)
3.65 (5.90)
0.51-6.79
Fixings (%)
6.99 (6.96)
3.28-10.70
Haemorrhage
Time (%)
6.51 (6.01)
3.30-9.71
Fixings (%)
0.26 (0.84)
-0.18-0.71
Carotid pulse
Time (%)
0.32 (1.04)
-0.23-0.86
Fixings (%)
0.15 (0.44)
-0.08-0.38
Radial pulse
Time (%)
0.19 (0.57)
-0.11-0.49
Time in circulation (s)
44.58 (29.45)
25.87-63.30
Disability
Fixings (%)
0.93 (1.27)
0.25-1.60
Eyes
Time (%)
1.21 (1.81)
0.25-2.18
Time in Disability (s)
38.50 (0.71)
32.15-44.85
Exposure
Fixings (%)
4.15 (8.27)
-0.26-8.56
Thermal blanket
Time (%)
3.75 (7.22)
-0.10-7.60
AED
Fixings (%)
1.60 (2.46)
0.29-2.91
Time (%)
1.35 (2.19)
0.18-2.51
Fixings and time of total and each viewpoint in percentage.
Time of each total section of ABCDE approach in seconds.
211
212 << Insert Figure 2 near here >>
213
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214 Discussion
215 Simulation training is a well-recognised educational tool in medical and
216 emergency personnel education that allow improvement of technical and non-technical
217 skills [17–19]. Eye-tracking technology was reported as effective instrument in order to
218 complement the simulation training and the subjects performance assessment [20,21].
219 Recent publications show its effectiveness assessing or evaluating in simulating
220 scenarios related to anaphylaxis or paediatric trauma [12,22]. In fact, the accuracy of
221 this tool also resulted in its using in real situations [23].
222 In our study, eye-tracking was used to analyse the lifeguards’ ABCDE approach
223 skills. Professional lifeguards showed differences when it comes to recognizing and
224 treating a critically ill patient in a simulated scenario. Although all the participants had
225 theoretical training and knew what was and how was applied the primary assessment,
226 they had not received simulation training and half of them had not used the primary
227 assessment in a real situation. Although there is no clear evidence that training "life
228 support in trauma" has an impact on the results of trauma victims, there is evidence that
229 educational initiatives improve knowledge about what to do in emergency situations
230 [24].
231 Most of rescuers of this study evaluated the Airway (14 of 20: 70%) and
232 Breathing (17 of 20: 85%) although only 4 (20%) and 5 (25%) assessed both correctly.
233 Only 40% evaluated Circulation. Of the subjects who performed the evaluation of
234 Circulation, only 3 took a central pulse and 2 checked a peripheral pulse. The
235 assessment of Circulation was the step that required the longest time assessment (45 s).
236 Maybe this was due to the haemorrhage that the simulator presented in the lower limb
237 as a distracting factor introduced by the researchers. The haemorrhage was small and
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238 produced by an erosion. The majority of the participants did not consider assessing
239 pulses neither peripheral nor central. This could be due to that the Guidelines of the
240 European Resuscitation Council as well as the Guidelines of the American Heart
241 Association of basic life support insist that taking the pulse is not a necessary measure
242 to establish the diagnosis of cardiorespiratory arrest [14,25]. However, the simulator did
243 not present a PCR and required a Circulation evaluation.
244 The application of a structured assessment system has become the norm in
245 trauma. This approach to the early recognition and treatment of life-threatening injuries
246 has been trained in trauma courses for decades [26,27]. In the study by Olgers et al. [28]
247 in which they investigated the use of the ABCDE approach by emergency doctors they
248 observed that this approach was used in 26% of patients. When ABCDE approach was
249 used it was done with high scores (83%). The reason why the doctors decided not to use
250 this assessment approach was because of the general clinical impression, the vital signs
251 registered by nursing or that the reason for the consultation does not suggest an unstable
252 patient [28]. In another study conducted in a hospital emergency department, it was
253 found that only 52% of patients were evaluated with the ABCDE approach, and 17%
254 were fully evaluated with precision [29].
255 In view of our results, it seems that the lifeguards are not competent performing
256 the ABCDE approach in a simulated scenario. With respect to the visual fixations, the
257 lifeguards were able to maintain an adequate attention and fixation, which means that
258 they are focused on looking. Around 60% of the fixations and the time of visual
259 fixations were dedicated to important areas of vision for the ABCDE approach. This is
260 independent of the decisions made at each moment because the eyes could be focusing
261 on the important parts and not knowing the decisions to make.
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262 Practical implications
263 The poor results found in this study are relevant and useful to re-design and to re-
264 organize the training of lifeguards in two ways. For one hand, more efforts are needed
265 to train in terms of ABCDE approach considering the correct order of the different steps
266 and its relevance in the sequence. On the other hand, ABCDE approach comprises a set
267 of different skills and knowledges whose competency might decrease over time. Hence,
268 lifeguards’ training should consider this aspect and periodically refreshing re-training
269 should be mandatory to maintain the skills quality.
270
271 Limitations
272 This is a simulation study; therefore, a real intervention could generate different
273 results, which we suppose it might be even worse than the observed in our trial. The
274 lack of experience of the participants in the use of the simulation methodology could be
275 a limiting factor. The subjects sample was small, so the results should be taken with
276 caution. Also, the duration of the scenario could be a limiting factor as well because we
277 do not know what could have happened in the case that the scenario had lasted longer.
278 The participants knew that they were under observation and this may have modified
279 their performance.
280
281 Conclusions
282 Professional lifeguards showed skill limitations in a simulated scenario that
283 required ABCDE approach. Evaluation by experts and eye-tracking technology detected
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284 many gaps in the assessment and treatment of an eventual critically casualty. Such
285 deficits should be considered in the re-design and implementation of lifeguards’ training
286 programmes.
287
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380
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381 Figure legends:
382 Figure 1. Descriptive analysis about participants’ capacity to perform ABCDE
383 approach.
384 Figure 2. Descriptive analysis about fixings performed by participants during ABCDE
385 approach.
386
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(which was not peer-reviewed) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity.
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"Dispatcher, Can You Help Me? A Woman Is Giving Birth". A Pilot Study of Remote Video Assistance with Smart Glasses
Article
Full-text available
  • Dec 2022
  • SENSORS-BASEL
Abstract: Smart glasses (SG) could be a breakthrough in emergency situations, so the aim of this work was to assess the potential benefits of teleassistance with smart glasses (SG) from a midwife to a lifeguard in a simulated, unplanned, out-of-hospital birth (OHB). Thirty-eight lifeguards were randomized into SG and control (CG) groups. All participants were required to act in a simulated imminent childbirth with a maternal–fetal simulator (PROMPT Flex, Laerdal, Norway). The CG acted autonomously, while the SG group was video-assisted by a midwife through SG (Vuzix Blade, New York, NY, USA). The video assistance was based on the OHB protocol, speaking and receiving images on the SG. The performance time, compliance with the protocol steps, and perceived performance with the SG were evaluated. The midwife’s video assistance with SG allowed 35% of the SG participants to perform the complete OHB protocol. No CG participant was able to perform it (p = 0.005). All OHB protocol variables were significantly better in the SG group than in the CG (p < 0.05). Telemedicine through video assistance with SG is feasible so that a lifeguard with no knowledge of childbirth care can act according to the recommendations in a simulated, unplanned, uncomplicated OHB. Communication with the midwife by speaking and sending images to the SG is perceived as an important benefit to the performance.
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Analysis of eye-tracking behaviours in a pediatric trauma simulation
Article
Full-text available
  • Oct 2018
Eye-tracking devices are able to capture eye movements, which are further characterized by fixations. The application of eye tracking in a trauma setting has not been explored. Visual fixation can be utilized as a surrogate measure of attention during the management of a trauma patient. We aimed to determine the feasibility of using eye tracking and to characterize eye tracking behaviours of pediatric emergency medicine physicians during management of a simulated pediatric trauma patient. Each participant was equipped with a head-mounted eye-tracking device during a standardized simulated pediatric trauma scenario. Each session was video recorded, with visual fixations defined as >0.2 seconds, and characterized by start time, duration, and the area of interest. Data from seven videos were analysed; 35% of eye fixations were directed towards the mannequin, 16% towards the monitor, and 13% towards the bedside doctor. Visual eye tracking in a trauma simulation is feasible. Frequency of fixations tends to be highest towards the patient. Eye tracking within trauma simulation may provide new insights into quality improvement and inform advancements in pediatric trauma.
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Challenges and Feasibility of Applying Reasoning and DecisionMaking for a Lifeguard Undertaking a Rescue Research
Article
Full-text available
  • Jan 2017
  • Int J Emerg Ment Health
In areas where lifeguard services operate, less than 6% of all rescued persons need medical attention and require CPR. In contrast, among areas where no lifeguard services are provided almost 30% require CPR. This difference indicates in importance of the lifeguard. Lifeguard work requires effective problem identification, diagnostic strategies and management decisions to be made in high-risk environments, where time is of the essence. The purpose of this investigation was to assess all variables involved in lifeguard work related to a water rescue, and how the information obtained could inform lifeguard training and therefore performance. Methods: By using the drowning timeline, the authors explored all variables involved in a single rescue event by inviting 12 lifeguards to complete a survey of their professional role using a three-round Delphi survey technique. The total potential number of decisions for each phase and sub-phases, the number of variables, the probability of a single event repeating, the duration of each sub-phase and amount of variables demanded per minute were measured. Each sub-phase was presented as predominantly rational (if less than 1 variable per/min) or intuitive (if more than 1/min). Results: The variables identified in sub-phases were: “preparation to work” (8 variables and 0.0001 variables/min) and “prevent” (22 variables; 0.03 variables/min); these sub-phases were predominately considered to lead to rational decisions. The variables identified during “rescue” (27 variables and 2.7 variables/min) and “first-aid” (7 variables and 1.7 variables) were predominantly considered intuitive processes. Conclusion: This study demonstrates the complexity of a decision-making process during the quick, physically and mentally stressful moments of rescuing someone. The authors propose better decision-making processes can be achieved by reducing the time interval between identification of a problem and making a decision. Understanding this complex mechanism may allow more efficient training resulting, in faster and more reliable decision-makers, with the overall benefit of more lives saved.
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Getting Inside the Expert's Head: An Analysis of Physician Cognitive Processes During Trauma Resuscitations
Article
  • Mar 2018
  • ANN EMERG MED
Study objective: Crisis resource management skills are integral to leading the resuscitation of a critically ill patient. Despite their importance, crisis resource management skills (and their associated cognitive processes) have traditionally been difficult to study in the real world. The objective of this study was to derive key cognitive processes underpinning expert performance in resuscitation medicine, using a new eye-tracking-based video capture method during clinical cases. Methods: During an 18-month period, a sample of 10 trauma resuscitations led by 4 expert trauma team leaders was analyzed. The physician team leaders were outfitted with mobile eye-tracking glasses for each case. After each resuscitation, participants were debriefed with a modified cognitive task analysis, based on a cued-recall protocol, augmented by viewing their own first-person perspective eye-tracking video from the clinical encounter. Results: Eye-tracking technology was successfully applied as a tool to aid in the qualitative analysis of expert performance in a clinical setting. All participants stated that using these methods helped uncover previously unconscious aspects of their cognition. Overall, 5 major themes were derived from the interviews: logistic awareness, managing uncertainty, visual fixation behaviors, selective attendance to information, and anticipatory behaviors. Conclusion: The novel approach of cognitive task analysis augmented by eye tracking allowed the derivation of 5 unique cognitive processes underpinning expert performance in leading a resuscitation. An understanding of these cognitive processes has the potential to enhance educational methods and to create new assessment modalities of these previously tacit aspects of expertise in this field.
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Eye-tracking technology in medical education: A systematic review
Article
  • Nov 2017
Background: Eye-tracking technology is an established research tool within allied industries such as advertising, psychology and aerospace. This review aims to consolidate literature describing the evidence for use of eye-tracking as an adjunct to traditional teaching methods in medical education. Methods: A systematic literature review was conducted in line with STORIES guidelines. A search of EMBASE, OVID MEDLINE, PsycINFO, TRIP database, and Science Direct was conducted until January 2017. Studies describing the use of eye-tracking in the training, assessment, and feedback of clinicians were included in the review. Results: Thirty-three studies were included in the final qualitative synthesis. Three studies were based on the use of gaze training, three studies on the changes in gaze behavior during the learning curve, 17 studies on clinical assessment and six studies focused on the use of eye-tracking methodology as a feedback tool. The studies demonstrated feasibility and validity in the use of eye-tracking as a training and assessment method. Conclusions: Overall, eye-tracking methodology has contributed significantly to the training, assessment, and feedback practices used in the clinical setting. The technology provides reliable quantitative data, which can be interpreted to give an indication of clinical skill, provide training solutions and aid in feedback and reflection. This review provides a detailed summary of evidence relating to eye-tracking methodology and its uses as a training method, changes in visual gaze behavior during the learning curve, eye-tracking methodology for proficiency assessment and its uses as a feedback tool.
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Eye Tracking: A Novel Approach for Evaluating and Improving the Safety of Healthcare Processes in the Simulated Setting
Article
  • Dec 2016
Introduction: Eye tracking, used to evaluate a clinician's eye movements, is an example of an existing technology being used in novel ways by patient safety researchers in the simulated setting. The use of eye-tracking technology has the potential to augment current teaching, evaluation, and research methods in simulated settings by using this quantitative, objective data to better understand why an individual performed as he or she did on a simulated or naturalistic task. Methods: Selected literature was reviewed with the purpose of explicating how eye tracking can be used by researchers and educators to evaluate error-prone processes. The literature reviewed was obtained by querying the databases PubMed, CINHAL, and Google Scholar using the key words eye tracking, patient safety, and medical errors from 2005 through 2015.An introduction to the use of eye tracking, including both theoretical underpinnings and technological considerations, is presented. In addition, examples of how eye tracking has been used in research studies conducted in both simulated and naturalistic settings are provided. Conclusions: The use of eye-tracking technology to capture the eye movements of novice and expert clinicians has provided new insight into behaviors associated with the identification of medical errors. The study of novices' and experts' eye movements provides data about clinician performance not possible with existing evaluation methods such as direct observation, verbal reports, and thinking out loud. The use of eye tracking to capture the behaviors of experts can lead to the development of training protocols to guide the education of students and novice practitioners. Eye-tracking technology clearly has the potential to transform the way clinical simulation is used to improve patient safety practices.
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Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality
Article
  • Nov 2015
As with other Parts of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), Part 5 is based on the International Liaison Committee on Resuscitation (ILCOR) 2015 international evidence review process. ILCOR Basic Life Support (BLS) Task Force members identified and prioritized topics and questions with the newest or most controversial evidence, or those that were thought to be most important for resuscitation. This 2015 Guidelines Update is based on the systematic reviews and recommendations of the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations , “Part 3: Adult Basic Life Support and Automated External Defibrillation.”1,2 In the online version of this document, live links are provided so the reader can connect directly to the systematic reviews on the ILCOR Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a combination of letters and numbers (eg, BLS 740). We encourage readers to use the links and review the evidence and appendix. As with all AHA Guidelines, each 2015 recommendation is labeled with a Class of Recommendation (COR) and a Level of Evidence (LOE). The 2015 Guidelines Update uses the newest AHA COR and LOE classification system, which contains modifications of the Class III recommendation and introduces LOE B-R (randomized studies) and B-NR (nonrandomized studies) as well as LOE C-LD (based on limited data) and LOE C-EO (consensus of expert opinion). The AHA process for identification and management of potential conflicts of interest was used, and potential conflicts for writing group members are listed at the end of each Part of the 2015 Guidelines Update. For additional information about the systematic review process or management of potential conflicts of interest, see “Part 2: Evidence Evaluation and Management of Conflicts of Interest” in this …
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Simulation Technology for Resuscitation Training: A Systematic Review and Meta-analysis.
Article
  • Apr 2013
Objectives: To summarize current available data on simulation-based training in resuscitation for health care professionals. Data sources: MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Web of Science, Scopus and reference lists of published reviews. Study selection: Published studies of any language or date that enrolled health professions' learners to investigate the use of technology-enhanced simulation to teach resuscitation in comparison with no intervention or alternative training. Data extraction: Data were abstracted in duplicate. We identified themes examining different approaches to curriculum design. We pooled results using random effects meta-analysis. Data synthesis: 182 studies were identified involving 16,636 participants. Overall, simulation-based training of resuscitation skills, in comparison to no intervention, appears effective regardless of assessed outcome, level of learner, study design, or specific task trained. In comparison to no intervention, simulation training improved outcomes of knowledge (Hedges' g) 1.05 (95% confidence interval, 0.81-1.29), process skill 1.13 (0.99-1.27), product skill 1.92 (1.26-2.60), time skill 1.77 (1.13-2.42) and patient outcomes 0.26 (0.047-0.48). In comparison with non-simulation intervention, learner satisfaction 0.79 (0.27-1.31) and process skill 0.35 (0.12-0.59) outcomes favored simulation. Studies investigating how to optimize simulation training found higher process skill outcomes in courses employing "booster" practice 0.13 (0.03-0.22), team/group dynamics 0.51 (0.06-0.97), distraction 1.76 (1.02-2.50) and integrated feedback 0.49 (0.17-0.80) compared to courses without these features. Most analyses reflected high between-study inconsistency (I(2) values >50%). Conclusions: Simulation-based training for resuscitation is highly effective. Design features of "booster" practice, team/group dynamics, distraction and integrated feedback improve effectiveness.
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Delay and performance of cardiopulmonary resuscitation in surf lifeguards after simulated cardiac arrest due to drowning
Article
  • Nov 2011
To describe time delay during surf rescue and compare the quality of cardiopulmonary resuscitation (CPR) before and after exertion in surf lifeguards. A total of 40 surf lifeguards at the Tylösand Surf Lifesaving Club in Sweden (65% men; age, 19-43 years) performed single-rescuer CPR for 10 minutes on a Laerdal SkillmeteÔ Resusci Anne manikin. The test was repeated with an initial simulated surf rescue on an unconscious 80-kg victim 100 m from the shore. The time to victim, to first ventilation, and to the start of CPR was documented. The mean time in seconds to the start of ventilations in the water was 155 ± 31 (mean ± SD) and to the start of CPR, 258 ± 44. Men were significantly faster during rescue (mean difference, 43 seconds) than women (P = .002). The mean compression depth (millimeters) at rest decreased significantly from 0-2 minutes (42.6 ± 7.8) to 8-10 minutes (40.8 ± 9.3; P = .02). The mean compression depth after exertion decreased significantly (44.2 ± 8.7 at 0-2 minutes to 41.5 ± 9.1 at 8-10 minutes; P = .0008). The compression rate per minute decreased after rescue from 117.2 ±14.3 at 0 to 2 minutes to 114.1 ± 16.1 after 8 to 10 minutes (P = .002). The percentage of correct compressions at 8 to 10 minutes was identical before and after rescue (62%). In a simulated drowning, 100 m from shore, it took twice as long to bring the patient back to shore as to reach him; and men were significantly faster. Half the participants delivered continuous chest compressions of more than 38 mm during 10 minutes of single-rescuer CPR. The quality was identical before and after surf rescue.
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