Experiential Learning

Fundació ACE, Institut Català de Neurociències Aplicades is a nonprofit Alzheimer’s center that provides diagnostic, treatment, and patient management services to the Catalan Public Health Service (Xarxa Hospitalària d’Utilització Pública, XHUP). The patients are usually referred to the Memory Clinic of Fundació ACE by primary care physicians or medical specialists because the patients, their family, or their physician felt that they could have a memory problem.
The data included in this analysis were drawn from 332 individuals (118 men, 214 women) who visited Fundació ACE between January 2006 and May 2010. We selected for study those who were classified as cognitively normal with preserved performance on each of two cognitive screening tests—the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975 (link)) ≥24 and the Clock Test (Del Ser, Sánchez, et al., 2004 ) ≥5—and had a Clinical Dementia Rating (CDR; Morris, 1993 (link)) of zero, were older than 49 years of age, and were functionally literate. From an initial sample of 513 individuals, the medical records were reviewed to exclude those individuals who did not meet the general inclusion criteria, or had a psychiatric or neurological disease, a focal lesion on brain computed tomography (CT) imaging, a history of alcohol or other substance abuse, and severe auditory or visual abnormalities including glaucoma and cataracts. From this group, a total of 332 healthy individuals were studied.
The subjects included in this study had no evidence of functional impairment secondary to decline in cognition and had at least minimal writing abilities. However, among older individuals living in Spain, especially women, there were reduced opportunities for educational experience due to the disruption caused by the Spanish Civil War and the Second World War. All of the participants lived in Barcelona, and their native language was either Spanish or Catalan. The neuropsychological assessment was administered in their native language: 204 Catalan, and 128 Spanish. It needs to be mentioned that participants were assessed in the language that they felt more comfortable with, but many of them spoke Catalan and Spanish equally well.
All of the data included in this report were obtained in compliance with the regulations of industrial assay, and the study followed the Declaration of Helsinki guidelines. Written informed consent was obtained from all participants prior to any research evaluations.

This study was approved by the institutional review boards of the Nathan Kline Institute for Psychiatric Research and the New York University School of Medicine. Participants were volunteers who responded to advertisements in local newspapers and flyers or were recruited from our currently active Memory Education and Research Initiative Program. All participants provided formal consent prior to being examined and were compensated up to $450.00. A total of 133 participants completed the baseline evaluation, and 51 of these took part in the optional lumbar puncture procedure. Of the 51 participants who had lumbar puncture, three were excluded because of evidence in their MRI scans of confluent deep or periventricular white matter hyperintensities, defined as one or more hyperintense lesions measuring at least 10 mm in any direction. One individual was excluded because of a Mini-Mental State Examination (MMSE) score below 28. Of the 47 remaining participants, 28 were diagnosed with major depressive disorder by a board-certified psychiatrist based on clinical evaluation and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID), leaving 19 comparison subjects. Of the 28 individuals with major depressive disorder, 21 (75%) had recurrent episodes. A Clinical Dementia Rating scale score was compiled for 33 participants, and none of these had a score above 0. Table 1 summarizes the demographic and clinical characteristics of the study participants.

Following each intubation, the operator completed a data collection form, which included the following information: patient demographics, occurrence of a failed prehospital intubation attempt, operator specialty, operator postgraduate year (PGY), indication for intubation, method of intubation, paralytic agent, sedative agent, reason for device selection, device(s) used, presence of difficult airway characteristics (DACs), number of attempts at intubation, outcome of each attempt, and occurrence of AEs.
Only patients undergoing orotracheal intubation in the ED were included in this study. This included patients who underwent unsuccessful attempts at intubation in the field. Methods of intubation included rapid sequence intubation (RSI), in which a paralytic agent was used; oral intubation, in which a sedative agent was used (SED); and oral intubation, in which no medications were used (OTI).
The operator had three options to choose from for the reason for device selection. If the intubation was a routine airway with no anticipated difficulty, then the device selection was marked “standard.” If the device was selected with the expectation of a difficult airway, the reason for device selection was “difficult.” If the operator was using the device to gain educational experience with the device, then it would be classified as “education.”
Standard preoperative difficult airway predictors have been shown to be challenging to apply in the emergency setting.^{8 (link),9 (link)} Thus, we developed a list of DACs that were feasible for the operator to determine prior to intubation in an emergent setting by brief examination of the patient. These include the presence of cervical immobility, obesity, large tongue, short neck, small mandible, facial or neck trauma, airway edema, blood in the airway, and vomit in the airway.
An attempt at orotracheal intubation was defined as insertion of the laryngoscope blade into the oropharynx, regardless of whether an attempt was made to pass the endotracheal tube. Each attempt was documented with one of three possible outcomes: 1) successful tracheal intubation with no additional attempts required, 2) inability to intubate with additional attempt (s) required, or 3) inadvertent esophageal intubation with additional attempt(s) required. Successful intubation was defined as correct placement of the endotracheal tube in the trachea as confirmed by end-tidal CO₂ capnometry, pulse oximetry, chest auscultation, observation of chest excursion, absence of epigastric sounds, and misting of the endotracheal tube.
Adverse events tracked in this study include the following: esophageal intubation, oxygen desaturation, witnessed aspiration, mainstem intubation, accidental extubation, cuff leak, dental trauma, laryngospasm, pneumothorax, hypotension, dysrhythmia, and cardiac arrest. Cricothyrotomy was not considered an AE as we considered it an alternative way to secure the airway (see Table 1 for definitions of these AEs).
The data forms were reviewed by the senior author (JCS). If the form had any missing data, it was returned to the operator for completion. If information on the form contained inconsistencies, the operator was interviewed by the senior author for clarification. The data forms were cross-referenced to professional billing and pharmacy records to identify any intubations performed without a corresponding data form. If an intubation was identified without a data form, the operator was given a data form to complete as soon as possible to ensure a maximal capture rate. During the study period, 93.8% of the airway forms were turned in at the time of intubation, and the remaining 6.2% were captured by cross-referencing, for an overall 100% capture rate.
The data were then entered into the electronic data-base program HanDBase 4.0 (DDH Software, Wellington, FL, www.ddhsoftware.com) for the Palm Pilot and iPad and were subsequently transferred to Excel for Windows 2010 (Microsoft, Redmond, WA). The primary outcome measures were the incidence of one or more AEs and the incidence of specific AEs.