Step-by-step: Translating deliberate practice to the bedside

Dear Editor,

We thank the authors of the accompanying correspondence for their engagement with our article and for their thoughtful commentary on our study.¹

We agree that simulation cannot fully replicate the complexity, cognitive demands, and emotional stress of a real pediatric cardiac arrest. These events represent some of the highest-stakes scenarios encountered in clinical practice. Nevertheless, simulation remains a cornerstone for resuscitation education and research, particularly for these rare events in which prospective clinical study is challenging, and where preparedness for high-acuity, low-occurrence events is essential. Simulation education and deliberate practice have been a standard, longstanding and effective component of established resuscitation training programs such as Pediatric Advanced Life Support (PALS), despite these stated limitations.

Determining how skills acquired in simulation translate to clinical practice remains an important area for future investigation. Although our simulation curriculum incorporated elements of resuscitation choreography, including ultrasound machine positioning, defibrillation pads, competing task prioritization, and team interactions, simulation cannot fully recreate the dynamic environment of a real resuscitation. To address these gaps, our team is planning structured analyses of real pediatric cardiac arrests using video review, evaluating and comparing the use of POCUS-assisted pulse checks and manual pulse checks. This will provide an assessment independent of the curriculum and help address the inherent limitations of simulation-based evaluation. We also plan to further use simulation in an in-situ setting to assess POCUS pulse check skill retention, decay and accuracy.

The authors of the correspondence also raise the important question of how the Res-US Pulse Check protocol might be validated against a clinically meaningful reference standard during real pediatric arrests. Validation in clinical practice will require a pragmatic approach. While invasive arterial pressure monitoring may represent an ideal physiologic reference standard, it is rarely available during emergency department cardiac arrests in our setting. We also agree that femoral arterial pulsatility on ultrasound should not be assumed to represent clinically effective circulation, particularly in low-flow states and without other clinical data. Our protocol therefore incorporates cardiac POCUS as part of the broader resuscitation assessment, rather than relying on femoral pulsatility alone.

As is often the case in pediatric resuscitation research, the evidence base for this question lags behind that of adult practice. In contrast, the adult literature provides substantial evidence supporting POCUS pulse checks, including high accuracy in detecting return of pulsatile flow in patients undergoing cardiopulmonary bypass compared with invasive arterial monitoring, improved accuracy compared with manual palpation in cardiac arrest, and reduced time to pulse detection.2, 3, 4 Collectively, these findings support the utility and benefits of POCUS-assisted pulse assessment in cardiac arrest. Although important pediatric-specific considerations and nuances remain to be addressed, the adult literature provides a foundation upon which future pediatric investigations can build.

We view the present study as an initial step toward defining a structured approach to POCUS integration in pediatric cardiac arrest. We hope this work helps establish priorities for future investigation and contributes to the growing evidence base supporting ultrasound integration into pediatric resuscitation.

CRediT authorship contribution statement

Maya Harel-Sterling: Writing – original draft, Supervision, Writing – review & editing. Tasuku Takadera: Writing – review & editing. Elana Thau: Writing – review & editing. Laura Simone: Writing – review & editing. Deborah Schonfeld: Writing – review & editing. Jabeen Fayyaz: Writing – review & editing. Noa Kvatinsky: Writing – review & editing. Sasha Litwin: Writing – review & editing. Lianne McLean: Writing – review & editing, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.