All posts by Tomoyki Endo

About Tomoyki Endo

I'm Tomoyuki in Sendai City in Japan. I'm a man in my 40's and an emergency physician and also a teacher/instructor of medical simulation center of our university. I have been dedicated to teaching emergency life support skills to whoever needs those skills. My hobbies are some sports such as jogging, cycling, badminton and skiing.

Perspective of ECMO/ECPR simulation

I’ve been enthusiastic about providing ECMO simulation for these several years.

In 2013, I created a half-day ECMO sim at Simulation Center of Tohoku University Hospital in Sendai and I’ve been holding this simulation almost every single month for ECMO practitioners.

This is focused on VA-ECMO at Emergency Department. ELSO guideline was used as a reference. In order to make it possible for learners to practice ECMO cannulation and initiation of ECMO, I developed a low cost imitated vascular model named “Endo-Circuit”.

Recently I published a research about the long term efficacy of my ECMO simulation with the “Endo-Circuit” on peer-reviewed journal; “Acute Medicine & Surgery”, doi: 10.1002/ams2.236

My research revealed that many ECMO practitioners in Japan have some sort of PROBLEMS and FEARS about ECMO practice before simulation and then they have gotten some positive change in their knowledge, skills and attitudes after simulation. Since this research was only based on their retrospective self-evaluation, it’s unsure that their actual ECMO practices have been changed and lead to safer management. However some of their answers show that their usage of ultrasound for needle puncture and confirmation of guidewire placement during cannulation increased than before.

Even though the model is less expensive and imperfect in terms of anatomy of cardiovascular system, their evaluation about the circuit as a training model is relatively high. In order to keep quality of ECMO practice, this kind of simulation should be provided constantly.

In addition to my ECMO simulation, Japanese Circulation Society (JCS) and Japanese Resuscitation Council (JRC) had developed a one-day post cardiac arrest syndrome (PCAS) care training course in 2014 including ECMO skill training with “Endo-Circuit” and added an integrated ECPR team simulation in 2016.

Fortunately I got a fantastic opportunity to talk about JCS PCAS care training with my original training model at AHA/JCS Joint Session of Resuscitation Symposium in 2016 in New Orleans.

On Nov 12, I gave a 20-min presentation about our special educational experience including ECPR video for enthusiastic ECMO/ECPR providers attending the session. I had practiced my presentation a lot before the session and indeed my presentation was successful in terms of letting them know our project. There were some respected resuscitation researchers at the session. It was an amazing experience. My counterpart was Dr. David F. Gaieski and he talked about current US status of ECPR implementation and training. There were some hot discussions related to this topic.

On Nov 13-14, I did a ECPR cannulation Demo at JCS Booth in Exhibition Hall. Several attendees enjoyed my training model and some gave me compliments about it. I spent such a fantastic time in New Orleans.

ECPR is always challenging in terms of cost, human resources, time sensitivity, difficulty of cannulation, combination with TTM, uncertainty of heat and neurological recovery etc.

To make ECPR validated, I believe the standardized training including cannulation practice should be held for every advanced resuscitation provider repeatedly like BLS/ACLS.

I want to stay in touch with current enthusiasm about ECMO/ECPR and keep providing decent simulation seminars for practitioners.

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My New Mission

 It’s been a long time from the last post on this blog site. My blog has been dead for a while. It took about 7 months to come back here.

The main reason of this dead period was due to dysfunction of the World Press Blog system. I could not figure out how to fix it and then I left the problem as it was. Recently my blog has recovered after updating the system to the new version. Ironically the problem seemed to be very simple.

The second reason that my silent period was so long is because of much less free time to write blog. Up until the end of this March, I had been working at Tohoku University Hospital in Sendai City as both an emergency physician and a simulation educator for more than a decade. Sendai is the biggest city in Tohoku (north-east) area, which has more than a million people. And then in this April I have moved to my new workplace, “Tohoku Medical and Pharmaceutical University (TMPU) Hospital” in the same city as only one emergency physician in the hospital. This is a transforming event in my life.

My mission is to establish a completely new emergency center in the current hospital, which had been a relatively small local hospital of about 400 beds with neither emergency room nor emergency physicians and to create a whole new culture about emergency and disaster medicine. This hospital is located very close to the north-east coast of main land hit by gigantic tsunami in 2011.

Here I want to explain about the outline and perspective of this new medical university and hospital in Japan. TMPU is the 81st medical college in Japan, and interestingly enough the period from the last one established in Okinawa to TMPU is 37 years. It’s quite long. Japanese government had stopped to build a new medical school in 1979 because of controlling and limiting the numbers of physicians intentionally.

Despite the government policy, the shortage of physicians has been a big concern around Tohoku area for many years. In addition to this preexisted imbalance of physician resources, the 2011 huge earthquake and Tsunami disaster occurred in Tohoku area made this situation worse. Nowadays physician shortage makes it much more difficult for rural hospitals to hire attending physicians and then some hospitals have to stop clinical practice of some specialties. Not only the shortage of attending physicians in hospitals, but some elderly outpatient-clinic physicians in charge of local medical care are retiring.

Because of the urgent need of getting physicians in Tohoku area, Japanese government eventually decided to establish a brand new medical college in 37 years. TMPU encourages new medical students to being physicians dedicated to Tohoku area in the future. That means physicians of TMPU should also commit themselves to teaching and coaching them and being role models of them.

That’s the story of my new workplace. Because medical education, especially simulation about emergency medicine has been my favorite field for many years, I’m very excited about this new mission.

Since I’m only one emergency physician this year, I have to do bunch of stuff every day. Even worse, our hospital has few residents, therefore I’m in charge of almost of all small stuff. On the other hand, several general physicians and a nurse practitioner help me deal with emergency patients and caring admitted patients. I can’t thank them enough. I really appreciate their contribution to our emergency center.

Next year one more well-trained emergency physician will come to my hospital. That will make things much better.

In order to make our emergency center team much stronger, I create the code for our team. I’m really excited about developing super positive team.

Our Code
 
1.We Do The Best We Can
 
2.We Always Learn, Grow and Share Our Mind
 
3.We Stay Positive and Don’t Allow Negativity
 
 
 
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My New Battle Field!

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This is my new battle field, the ED of Tohoku Medical and Pharmaceutical University Hospital.

This brand new medical school is founded for the first time in 37 years in Japan.

This university is the private one and the owner decided to buy and use a little bit old hospital as a university hospital, which has already existed for a long time in Sendai City.

Up until last fiscal year, this hospital has had less responsibility about caring emergency or acutely ill patients, but  in order to educate medical students in near future, this old mind has to be changed.

On April 1st, I move to this hospital as a director of emergency department to create completely new ED before medical school students will begin their clinical clerkship about 3 years later.

Since the current ED(photo)  has very limited space and equipment,  we cannot provide satisfying treatment for several patients at the same time.

I’m an only emergency physician in this hospital now. That means that every doctor in this hospital has to do some sort of emergency practice. But some docs are not confident with such practice.  Some nurses, too.

My current mission is not only to build new ED clinical setting appropriate for emergency and critical care (ECC) but also to do enough education about ECC and make practitioners confident with emergency medicine.

One feature of our ED is the ultrasound machine (picture above). This new US machine is brought into our ED in early April. We can do ophthalmology ultrasound exam with this. It is designed for emergency use and has only one touch screen for operation, neither buttons nor dials. It is very easy to clean the screen.  Wiping, that’s it!

IMSH 2016 in SanDiego!!

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I attended 2016 IMSH in San Diego in mid-January.

I enjoyed not only scientific meeting but other activities such as visiting ED-ECMO experts in SHARP Memorial Hospital, going to Cororado and  running around the bay area in the morning .

Even though I had been frustrated with my poor English skill, I could get a lot of information about cutting edge knowledge of simulation education and create new connection with other sim experts.

Happy New Year 2016!!

Happy New Year to Every Enthusiastic Simulation Expert!

The first post of this year is all about my very best simulation named “SimMarathon”.

I completed the 16th SimMarathon on December 29, 2015.
This endurance type crazy simulation seminar is definitely challenging for both facilitator and learners. If we were not enthusiastic about learning, it would make them stressed out by heavy tasks.

I love this simulation because there are very few fakes in terms of environment, patients’ data and devices used in this simulation.

This time, more than 20 healthcare providers joined and completed rather tough scenarios including two ECMO initiation, one REVOA and many Rapid Sequence Intubation (RSI) procedures for shock patients.

I have always wanted to add something new in this seminar, then one idea came up to my mind. That was an electric medical record, EMR. This time I let them write or add each patient’s information on pre-formatted word text and review them after each scenario finished. Even though the rpre-formatted style was not perfect yet, such tool will lead to much more realistic and effective education especially for young doctors.

Scenarios are as follows:

40M
CC: severe headache, vomiting
Diag: SAH(ruptured Acom aneurysm) with Takotsubo cardiomypathy
PH: none
Interventions: diazepam for seizure, brain CT, RSI→3D-CT Angio

44M
CC: burn
Diag: large burn by explosion, face to leg, TBSA 40%
PH: none
Interventions: fluid resuscitation based on Parkland formula, bronchoscopy and RSI, burn wound care

51M
CC: Trauma by falling from 4m height
Diag: traumatic SAH→VF due to AMI(Cardiogenic shock)
PH: HT
Interventions: Failed ACLS→VA-ECMO(ECPR) to manage persistent VF→PCI(POBA)

19M
CC: motorbike accident, blunt trauma, rt. chest pain
Diag: rt tension pneumothorax, rib fracture, aortic injury, lung and liver contusion
PH: none
Interventions: needle decompression→chest tube, CECT, IVR, BP control

53M
CC: altered consciousness, vomiting, sweating, miosis, fasciculation
Diag: organophosphate poisoning
PH: HT, HL, depression
Interventions: airway emergency by massive secretion→RSI, atropine + PAM

50F
CC: syncope,chest discomfort
Diag: long flight→DVT/massive PE (Clinical Scenario 5)
Interventions: limited amount of fluid resuscitation, RSI with ketamine/catecholamine→VA-ECMO→CECT
PH: overweight

66M
CC: altered consciousness, severe shock, vomiting and diarrhea
PH: none
Diag: AOSC, septic shock
Interventions: EGDT with Norad and vasopressin, EST/ENBD

16F
CC: death leap
Diag: pelvic fracture, multiple limb fractures, hemorrhagic shock, rt. pneumothorax
PH: very early phase of pregnancy
Interventions: transient responder →REVOA(IABO), blood O-type transfusion → CECT→TAE to blt internal iliac arteries

Report of SimMarathon in Autumn, 2015

I’ve forgotten to upload about my original simulation seminar called “SimMarathon” that was held on Nov 3rd, 2015.

At that time, 11 doctors and 6 nurses participated in this simulation.
They were divided into two teams and managed scenarios one after another.
Two doctors were attending emergency physicians and both gave a lot of comments and tips for young doctors.
Even though each scenario was so sick and difficult to handle, they did their best to make the patients stable as a team.
I had prepared 10 scenarios for this 8-hour sim, but just 7 scenarios were completed.
Especially ECMO scenarios took longer time than other ones, for example more than 1.5 hours for persistent VF scenario.
I know that too much complicated and comprehensive scenario that has bunch of teaching points is not suitable for less experienced learner, but that is the case they will have to deal with in the near future.
 Scenarios were as follows;

55M
CC: dyspnea, altered consciousness
Diag: severe pneumonia of Legionella
Interventions: intubation/EGDT/ABX→ventilatory support

60M
CC: hypothermia, fine VF
Diag: accidental hypothermia with GI bleeding
Interventions: ECMO, defib after rewarming more than 30 degree, massive blood transfusion, endoscopic/operative hemostasis

20F
CC: blunt trauma, hemorrhagic shock
Diag: facial trauma, hemorrhagic shock due to fractures of pelvis and multiple limbs
Interventions: cricothyroidotomy for airway emergency with multiple facial bone fractures, massive blood transfusion, FAST/FACT→TAE→external fixation of pelvis

60M
CC: lt.hemiparesis, altered consciousness
Diag: AAD(Stanford A), dissection 3 branches of aortic arch, seizure
Interventions: intubation, CE-CT→ope

20F
CC: altered consciousness, fever
Diag: bacterial meningitis/septic shock/sepsis-induced cardiomyopathy
interventions: blood culture, intubation, EGDT, early ABT administration(MEPM/VCM), CT, lumbar puncture

44M
CC: burn by explosion, face to leg,
Diag: large burn with inhalation injury, TBSA 40%, hemoglobinuria
Interventions: fluid resuscitation according to Pakland formula, bronchoscopy, intubation, wound care

51M
CC: Fall from 4m hight, VF during CT scan
Diag: traumatic SAH, rib fractures, transverse process fracture of lumbar spine, retroperitoneal hemorrhage,
new onset of AMI(broad anterior), persistent/reccurent VF
Interventions: VA-ECMO, PCI(only POBA) with minimum heparinization

REBOA Insertion Training

This is the first time for me to let learners put the real REBOA catheter into my original water vascular circuit made for ECMO training.

REBOA means “Resuscitative Endovascular Balloon Occlusion of the Aorta”. This is used for temporary control of life-threatening hemorrhage caused by trauma or other etiology like AAA up until definitive therapy will have been done.

Actually, my circuit worked well!

I’ve realized that my original circuit is quite useful not only for  ECMO training but also trauma simulation 🙂

Since the internal diameter of this vascular model is about 12mm, full inflation of the balloon couldn’t be done in this model.

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The movie and picutures show Zone 1 placement of the balloon

My Lecture about CPR for Lay Rescuers (Only in Japanese)

This is my lecture about CPR for lay citizens on Nov 7, 2015.

After the lecture, about one hundred attendees actually did CPR training with special training tools and manikins.

This was held for Japanese lay citizens so that the spoken language is Japanese.

Tohoku University Hospital in Sendai hosted this event.

I modeled cardiac arrest patient right after collapse for this lecture.  In this lecture I gave a quiz about CPR quality. Please check it out!

 

My Experience of 5 min Q-CPR Challenge!

Yesterday, I tried 5min continuous chest-compression challenge with ResusciAnn with Q-CPR of Laerdal company. This time I chose the challenge without ventilations.

Challengers have to compress the chest just between 5.0 and 6.0 cm in depth without any aids such as metronome, depth indicator and countdown timer.

If they compress either less than 5.0cm or more than 6.0cm, that’ going to be judged inappropriate. In addition, the speed and chest recoil (or leaning) are also being evaluated during the challenge.

For me, five minutes were a little bit long and demanding, actually.

The result (Photo) was not the perfect one. Even though the speed of 111/min and chest recoil were perfect, the mean depth was 6.1cm!IMG_2360

I just compressed 0.1cm too much for 5min on average. It’s a shame!!

I realized that doing compressions in depth between 5.0 and 6.0 cm based on 2015 CPR guideline is a kind of an artistic performance for professional healthcare providers!

SimNight on Oct 27, 2015

This night, 2 young doctors, 1 nurse and their senior doctor participated in this simulation.
I gave just one scenario of a severe community acquired pneumonia patient that has several teaching points.

It took about 50 min for them to complete the scenario and then I did about one hour thorough debriefing.

After the scenario, these young docs seemed to be overwhelmed by the severity of the patient and their lack of ability to manage this patient. One of them said  “I’ve realized what I don’t know and what I should learn now.”

I believe this Sim has gotten them motivated and urged them to learn about emergency medicine more.

【Case】 55 years old, MaleCC: dyspnea, altered consciousness
PH: HT
By ambulance
Condition: severe pneumonia of Legionella, tachycardic AFib → NPPV:unsuccessful→intubation/EGDT/ABX(LVFX)→ventilatory support