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Background Split liver transplantation addresses donor shortages by facilitating the transplant of two recipients using one donor liver. Some still consider these grafts inferior due to prolonged cold ischaemia time and at times difficult vascular reconstruction. Techniques such as in-situ splitting, machine perfusion and interposition grafts may address these challenges and thereby address these concerns. The aim of this review is to assess these technical advances in split liver transplantation, their utility and outcomes. Methods A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Keywords included ‘split liver transplantation’, ‘arterial reconstruction’, and ‘machine perfusion’. Data found was synthesised into sections including: methods of splitting, full-left full-right splitting, donor cholangiography, machine perfusion and arterial reconstruction. Results A total of 78 articles met inclusion criteria after screening of 151 eligible articles. These were subdivided into the following categories: in-situ (25), ex-vivo (25), full-left full-right splitting (15), donor cholangiography (2), machine perfusion (6), and arterial reconstruction (5). The in-situ splitting technique reduces the cold ischaemia time compared to the ex-vivo technique which may improve graft quality and liver splitting during normothermic machine perfusion is a novel technique with the potential to incorporate the best aspects of both techniques. Interposition grafts are often required during split liver transplantation but have an increased risk of hepatic artery thrombosis. Conclusion Advancements in technique have allowed many of the unique challenges of split liver transplantation to be overcome. Overall, this supports the use of split liver transplantation in broader and riskier settings and we advocate for liver transplant surgeons to not hesitate in using these grafts liberally and expanding their recipient selection criteria.

Background Paediatric resuscitation and stabilisation is common in district general hospitals.1 This complex and often stressful situation involves medical and nursing teams from different specialties working collaboratively together. Early on in the COVID 19 pandemic an infant presented acutely with respiratory failure, cardiogenic shock and seizures. This case was challenging due to the clinical complexity, re-location of paediatric resuscitation facilities during the surge and the impact of personal protective equipment (PPE) on communication. We describe the use of in situ simulation and a locally adapted cognitive aid to enhance the delivery of paediatric resuscitation care during the global pandemic. Summary of Work Since April 2020 we have run over 20 in situ paediatric emergency simulation scenarios initially thrice weekly for staff exposure to fortnightly sessions currently. Scenarios include paediatric sepsis, head injury, bronchiolitis or a recent paediatric case. On call teams from anaesthesia, critical care, emergency medicine and paediatrics are invited through the hospital paging system to attend a ‘Paediatric Simulation Emergency Scenario’ in the Emergency Department. Attendance is multi-disciplinary and usually involves 8–10 staff members per session. Scenarios incorporate the use of a locally developed Paediatric Emergency Intubation Checklist (figure 1) allowing a shared mental model of the COVID adaptions to intubation and ventilation. Simulation sessions last approximately 45 minutes including a debriefing section focused on communication and teamwork. Results and Discussion Simulation training has allowed us to adapt paediatric resuscitation facilities improving access to the patient, visibility of monitoring, access to advanced airway and resuscitation equipment and designated areas for donning and doffing of PPE. Qualitative staff feedback suggests the impact of regular in situ simulation and a locally adapted intubation checklist improved confidence and communication within a team working in a new location during the global pandemic. Improving team performance is integral to improving patient safety and clinical care. Conclusion We have used our understanding of human factors2 surrounding the case highlighted to inform quality improvement, change logistical process and promote ongoing learning and communication through simulation. References Paediatric Intensive Care Society. Quality standards for the care of critically ill children. 2015 Systems Thinking for Everyday Work. A Safety Improvement Model for Healthcare. NHS Education for Scotland. 2018.

Background With the rising Covid-19 pandemic, it became clear that we would need to dramatically expand our ICU in bed capacity and trained staff. Additional theatre staff became available, but there was very limited time to train them. The ‘Covid sims’ were developed as a tool to train hundreds of staff in a short space of time, in the week before the pandemic was modelled to escalate in our hospital. Summary of Work In just one week, over 200 members of theatre, ED and critical care staff attended the ‘Covid sims’. The training covered: Demonstration and practice of donning and doffing PPE. Simulation station incorporating adaptations required for intubation and ventilation of the Covid patient, alongside demonstrations of the theatre anaesthetic machines and ICU ventilators. Demonstration and explanation of proning, followed by guided practice. Teamwork; the mix of skill sets of those attending mimicked a team presenting for a shift – ODPs, anaesthetists, physiotherapists, ICU doctors and nurses and critical care outreach staff. This enabled staff to develop their new team roles in a simulated environment prior to the pandemic arriving. Summary of Results Over 200 members of staff were trained over the course of one week. This enabled the expansion of the ICU across elective theatres, tripling our usual maximum ICU capacity. Feedback from the sims reflected the full range of attendees. Specific aspects mentioned were: development of confidence and competence with practising new skills, standardised training enabling standardised care and facilitating teamwork, addressing knowledge gaps, improved safety, appropriate timing to retain knowledge and skills. Increased confidence and reduced anxiety were universal in the respondants. Discussion and Conclusions Simulated sessions are an effective way to train a large group of staff with different skill sets in a very short amount of time. From feedback received, staff felt more confident in their own competence, less anxious about what was required of them and more able to meet the challenges of the surge when it happened. Recommendations The merits of simulation for acquisition of technical skills and improvements in team performance have been demonstrated in multiple prior studies. Despite improvements in confidence and reductions in anxiety not being a primary aim of these simulations, their prevalence was prominent in the feedback, over and above technical skills. It would be of interest to look into this in more detail using semi-structured interviews and a thematic analysis. Reference Goldshtein D, Krensky C, Doshi S, et al,In situ simulation and its effects on patient outcomes: a systematic review. BMJ Simulation and Technology Enhanced Learning 2020;6:3–9. Rosen MA, Hunt EA, Pronovost PJ, Federowicz MA, Weaver SJ. In situ simulation in continuing education for the health care professions: a systematic review. J Contin Educ Health Prof 2012;32(4):243–254. doi:10.1002/chp.21152

Background The Intensive Care Unit of the Royal Berkshire Hospital, Reading, is a 17-bedded general critical care unit with over 1000 admissions per year. Since 2015, multidisciplinary in-situ simulation has been delivered approximately twice per month and is now a well-established part of the unit’s education programme. In-situ simulation continues to develop as an educational tool (Rosen et al, 2012), and has been shown to be effective in the critical care setting (Theilen et al 2017). Summary of work In-situ simulation forms part of a weekly teaching programme on the Intensive Care Unit. Scenarios are led by a consultant intensive care physician with experience in delivering simulation education. They are supported by a member of junior medical staff working in a clinical fellow post with an emphasis on simulation and education. Doctors and nurses participate in each session, occasionally with allied health professionals. Simulation is delivered using a mannequin with monitoring in an empty clinical bed space. Participants use actual equipment and medications (with the exception of controlled drugs). Scenarios cover a broad range of topics, from high frequency events to infrequent medical emergencies (e.g. intubation of a septic patient with pneumonia, obstructed and/or displaced tracheostomy). The debrief covers the clinical aspects with a strong focus on the human factors, team working and practical issues. Participants and observers are invited to provide feedback following the sessions. Summary of results Over 70 feedback responses have been collected over the course of the programme to date. Respondents are consistently positive, agreeing that the scenarios are relevant, useful for learning and improve confidence. Free-text responses frequently referred to realism, learning about team work and the benefit of practicing infrequent emergencies. Improvements suggested included removing observers from the bed space to avoid confusion, clarity of what equipment can be used and the opportunity to improve fidelity with mock patients on the electronic patient record. Discussion, conclusions and recommendations In-situ simulation is an acceptable and useful format for teaching in the intensive care unit. Learning for staff covers both the clinical topic of the emergencies, as well as human factors. Future initiatives will aim to improve patient safety further by acting on latent threats identified during simulations, developing scenarios in response to safety incidents reported locally and nationally, and identifying risks associated with the physical structure of the area. References Rosen, M. A., Hunt, E. A., Federowicz, M. A. & Weaver, S. J.,. In situ simulation in Continuing Education for the Health Care Professions: A Systematic Review. Journal of Continuing Education in the Health Professions 2012, 32(4), pp. 243–254. Theilen, U., Fraser, L., Jones, P.,Leonard, P. & Simpson, D., 2 017. Regular in-situ simulation training of paediatric Medical Emergency Team leads to sustained improvements in hospital response to deteriorating patients, improved outcomes in intensive care and financial savings. Resuscitation, 115, pp. 61–67.

Introduction Inter-professional in-situ simulation has been an integral part of the ICU education programme at the Royal Berkshire since 2015. Simulation has become a well-established, routine part of the working of our unit running twice a month. Participants’ feedback has always been positive. We aspired to build on this, extend the reach of our simulation programme and seek to maximise its impact on patient safety. We describe how we have used our in-situ simulation to develop organisational learning¹ in our unit and manage latent threats². Method Our approach to extend the reach of our simulation and maximise impact on patient safety has been multifaceted. In 2016 we started producing a newsletter which is used to disseminate the learning points of the simulation and key features from the debrief to members of the team which have been unable to attend. This is disseminated to all team members via email, and a number of copies are printed and displayed in the department and coffee room. In addition to the inter-professional education aims of the simulation programme, we are using the simulation programme to identify latent threats present on our Intensive Care Unit. Running scenarios in stocked and prepared vacant bed-spaces, and using disposables, equipment and medicines with simulated patients in the same way they are for real patients has enabled the processes and systems in our unit to be tested. Results In the 24 months from September 2016 to September 2018 we identified 16 latent safety threats through the use of simulation. These ranged from staff knowledge on the use of certain equipment to environment to problems with the setup and layout of the department. We identified six latent threats due to the environment, five due to equipment issues, and five related to knowledge and education. These have been shared with staff via the newsletter, and where possible, rectified after the simulation and where necessary escalated via the hospital incident reporting system. Conclusion The benefits of in-situ simulation can extend beyond simply educating the participants. We have used our simulation programme to develop our department as ‘a learning organisation’, educating ourselves about the working dynamics of our department and revealing latent safety threats. This has enabled us to increase staff awareness of these issues via our newsletter and take steps to mitigate them - making our department safer. References Knight P, MacGloin H, Lane M, Lofton L, Desai A, Haxby E, Burmester M, et al. (2018). Mitigating Latent Threats Identified through an Embedded In Situ Simulation Program and Their Comparison to Patient Safety Incidents: A Retrospective Review. Frontiers in pediatrics, 5, 281. Carroll JS, Edmondson AC. (2002) Leading organisational learning in health care BMJ Quality & Safety2002;11:51-56.

Background Acute airway compromise is a leading cause of paediatric cardiopulmonary arrest.1 Working in a District General Hospital (DGH) however, critical paediatric airway emergencies remain rare. It is essential that teams remain primed to respond rapidly when the need arises. Effective cross-speciality communication and access to familiar equipment are essential to prevent potentially devastating delays. Simulation is becoming an increasingly important tool to interrogating current practice, identifying problems and implementing change before patient harm occurs.2 Summary of work We ran an in-situ simulation using a high fidelity paediatric model to test our departmental response to a paediatric airway emergency involving multiple clinical teams. Run in real time, we recorded: the sequence of events; timings of key interventions and inter-team communication; and any equipment issues which arose. Summary of results We demonstrated a number of avoidable delays which could significantly impact patient safety. The at-risk airway was recognised at just 5 minutes however it was 46 minutes until advanced paediatric airway support arrived. A further 14 minute delay occurred following anaesthetic induction, before the airway was secured, as appropriate paediatric advanced ENT airway equipment was not available in the emergency theatre. Discussion and conclusion The absence of a clear pathway for escalation of paediatric airway concerns caused significant delays. Responders were uncertain who they should contact to rapidly access appropriate help. The greatest risk to impending airway obstruction however was the lack of appropriate ENT equipment in theatre following anaesthetic induction. Recommendations Working directly with the on-call ENT team we have developed a clear pathway and identifiable trolley to include both anaesthetic and ENT emergency paediatric airway equipment. This universal (Make Airways Safe) MAST trolley is now standardised in ED and emergency theatres, minimising delays in that could potentially jeopardise the care of the critically ill child. We are replicating the MAST trolley in neighbouring DGHs covered by the same ENT on-call team. Our aim is to generate a standardised regional equipment trolley, increasing patient safety in time-critical airway emergencies. References Kuisma M, Suominen P, Korpela R. Paediatric out-of-hospital cardiac arrests-epidemiology and outcome. Resuscitation. 1995 October;30(2):141–50. Davison M, Kinnear FB, Fulbrook P. Evaluation of a multiple-encounter in situ simulation for orientation of staff to a new paediatric emergency service: a single-group pretest/post-test study. BMJ Simul Technol Enhanc Learn 2017 October;3(4):149–153.

Propranolol is a highly lipid-soluble beta-receptor antagonist. We describe a case of mixed overdose, including propranolol, amlodipine and olanzapine, resulting in severe resistant hypotension which was successfully treated. A 21-year-old student ingested 6.4 g of propranolol, 280 mg of amlodipine and 560 mg of olanzapine. The patient was brought to the emergency department and exhibited signs of severe systemic toxicity – profound hypotension and circulatory collapse, respiratory depression and coma. The patient had conventional therapy but failed to respond to this and was therefore commenced on IntraLipid infusion, high-dose insulin infusion and inotrope infusion. An endoscopy was performed in intensive care which revealed a large drug beozar – this was removed. We believe that this combination of infusions with early endoscopy could be beneficial in treating similar patients in the future and present the first case of a propranolol drug bezoar.

Reflection is a cognitive process in which new information and experiences are integrated into existing knowledge structures and mental models, resulting in meaningful learning. Reflection often occurs after an experience is over, promoting professional development and lifelong learning. However, a reflective emergency physician (EP) is also able to apply reflection in real time: self-monitoring, coping with the unexpected, and quickly thinking on his or her feet to solve complicated, unique, and challenging clinical problems. Reflection is a skill that can be taught and developed in medical education. Evidence demonstrating the value of teaching reflection is emerging that substantiates longstanding educational theories. While a few educators have started to explore the use of reflection for emergency medicine (EM) learners, the potential for broader application exists. This review summarizes the literature regarding reflection in medical education and provides a basic primer for teaching reflection.

BACKGROUND: Capsule endoscopy (CE) has been shown to produce a high diagnostic yield in patients with obscure gastrointestinal bleeding (OGIB); however, in those with negative studies, management is controversial. Very few studies have reported on repeat CE in the same patient; data regarding this diagnostic strategy are limited.OBJECTIVE: To determine the diagnostic yield of repeated CE studies and how this yield affects subsequent patient management.METHODS: A retrospective chart review of all patients who underwent CE at St Paul’s Hospital (Vancouver, British Columbia) between December 2001 and June 2009 was conducted. Patients who underwent subsequent repeat CE were identified and divided into one of four subgroups. Findings were classified as positive or negative.RESULTS: Eighty-two of 676 patients underwent more than one CE study. Group 1 (incomplete study) included 22 patients (27%) and yielded 10 positive findings (45%). Group 2 (screening) comprised four patients (5%) and yielded two positive findings (50%). Group 3 (ongoing symptoms despite previous negative study) totalled 26 patients (32%) and yielded 10 positive findings (38%). Group 4 (previous positive study with treatment/investigation) included 30 patients (37%) and yielded 23 positive findings (77%). Overall, the present study found positive findings in 55% (45 of 82) of repeated CE cases, which resulted in a change in management in 39% (n=32) of the patients.CONCLUSION: Due to the high diagnostic yield and noninvasive nature of CE, repeat CE appears to be of benefit and should be considered for specific patients before other types of small bowel studies.

Art of Analysis (AoA) is a cooperative effort of the Ohio State University College of Medicine (OSUCOM) and Columbus Museum of Art (CMA) aimed at medical students who are participating in learning communities, groups formed in pre-clinical medical student education to emotionally support and encourage students through the arduous process of medical training, to develop critical thinking skills; engender empathy; increase tolerance for ambiguity; build team problem solving abilities; and consider multiple perspectives through the observation of artwork. While several medical education institutions in the past have described similar programs, AoA uses a unique critical thinking strategy called “ODIP” (Observe, Describe, Interpret, Prove). Group participants include medical students, the learning community faculty (faculty members from OSUCOM) and CMA educators who facilitate and direct the AoA program. The groups set expectations before the program, emphasizing the goals and objectives of the program. Students then use the ODIP strategy to interpret one work of art as a group before they individually venture into the galleries to find artwork that answers a question posed by facilitators. Students present their theories and defend these ideas in a group discussion format during the two-hour program. The formalized ODIP process provides a framework for students to express their ideas, and by utilizing learning communities create an opportunity for openness and discussion that may not exist between new acquaintances participating in the AoA program de novo. The ODIP strategy is not unique to the AoA program but has been developed by CMA in its efforts to aid critical and personal interpretations of artwork. It is designed to apply to various learners, and is easily applicable to the adult-style learners with varying backgrounds unique to medical training. It is the goal of the AoA program to create abilities in teamwork, tolerance of alternate ideas, an empathy particular to the visual arts, and critical thinking skills. Correlation between the AoA program and ODIP format can easily be made with medical rounds and the process of developing a differential diagnosis as healthcare continues to transition into a more inclusive, multi-disciplinary team approach to health and disease prevention. The AoA program at CMA serves as an important tool in the education of physicians at OSUCOM, helping in the development of skills essential to the clinical practice of medicine.

Simulation experiences have begun to replace traditional education models of teaching the skill of bad news delivery in medical education. The tiered apprenticeship model of medical education emphasizes experiential learning. Studies have described a lack of support in bad news delivery and inadequacy of training in this important clinical skill as well as poor familial comprehension and dissatisfaction on the part of physicians in training regarding the resident delivery of bad news. Many residency training programs lacked a formalized training curriculum in the delivery of bad news. Simulation teaching experiences may address these noted clinical deficits in the delivery of bad news to patients and their families. Unique experiences can be role-played with this educational technique to simulate perceived learner deficits. A variety of scenarios can be constructed within the framework of the simulation training method to address specific cultural and religious responses to bad news in the medical setting. Even potentially explosive and violent scenarios can be role-played in order to prepare physicians for these rare and difficult situations. While simulation experiences cannot supplant the model of positive, real-life clinical teaching in the delivery of bad news, simulation of clinical scenarios with scripting, self-reflection, and peer-to-peer feedback can be powerful educational tools. Simulation training can help to develop the skills needed to effectively and empathetically deliver bad news to patients and families in medical practice.

AIM: To identify patient risk factors associated with incomplete small bowel capsule endoscopy (CE) studies. METHODS: Data from all CE procedures performed at St. Paul’s Hospital in Vancouver, British Columbia, Canada, between December 2001 and June 2008 were collected and analyzed on a retrospective basis. Data collection for complete and incomplete CE study groups included patient demographics as well as a number of potential risk factors for incomplete CE including indication for the procedure, hospitalization, diabetes mellitus with or without end organ damage, limitations in mobility, renal insufficiency, past history of bowel obstruction, abdominal surgery, abdominal radiation therapy and opiate use. Risk factors were analyzed using a univariable and multivariable logistic regression model. RESULTS: From a total of 535 CE procedures performed, 158 were incomplete (29.5%). The univariable analysis showed that CE procedures performed for overt gastrointestinal bleeding (P = 0.002), and for patients with a prior history of abdominal surgery (P = 0.023) or bowel obstruction (P = 0.023) were significantly associated with incomplete CE studies. Patients on opiate medications (P = 0.094) as well as hospitalized patients (P = 0.054) were not statistically significant, but did show a trend towards incomplete CE. The multivariable analysis showed that independent risk factors for an incomplete CE procedure include prior history of bowel obstruction [odds ratios (OR) 2.77, P = 0.02, 95% confidence intervals (CI): 1.17-6.56] and procedures performed for gastrointestinal bleeding (Occult OR 2.04, P = 0.037, 95% CI: 1.04-4.02 and Overt OR 2.69, P = 0.002, 95% CI: 1.44-5.05). Patients with a prior history of abdominal surgery (OR 1.46, P = 0.068, 95% CI: 0.97-2.19), those taking opiate medications (OR 1.54, P = 0.15, 95% CI: 0.86-2.76) and hospitalized patients (OR 1.82, P = 0.124, 95% CI: 0.85-3.93) showed a trend towards statistical significance. CONCLUSION: We have identified a number of risk factors for incomplete CE procedures that can be used to risk-stratify patients and guide interventions to improve completion rates.