Exploring the knowledge and practice of calcium channel blocker overdose management among South African Emergency Medicine doctors.

This paper aims to examine the current practice of Emergency Department (ED) doctors in the utilisation of chest x-rays (CXRs) for the diagnosis of abdominal pain. It also aims to examine ED doctors' attitudes towards evidence-based medicine (EBM) and the perceived barriers to implementing EBM at workplaces. A cross-sectional survey of ED doctors' utilisation of CXR for abdominal pain and their attitudes and perceived barriers to EBM was conducted using a modified validated questionnaire. The first section explored current practice and knowledge around the use of CXRs for patients who present with abdominal pain. The second section examined ED doctors' attitudes and approach to EBM. The final section examined ED doctors' implementation of EBM strategies in their workplace. The survey was completed by 48 ED doctors from 16 different emergency departments throughout NSW. Almost 90% of participants (n = 43/48) agreed or strongly agreed that EBM was important in daily practice. 62.5% (n = 30/48) agreed or strongly agreed that their current practice was backed by EBM guidelines; however only 23% (n = 11/48) agreed or strongly agreed that they rely on scientific evidence only when making clinical decisions. 16.7% (n = 8/48) agreed or strongly agreed that changing current procedures at their workplace was straightforward. ED doctors have positive attitudes towards EBM, even though they do not always rely solely on evidence for their practice. ED doctors are aware of the limitations of CXRs for the assessment of abdominal pain and are open to implementing guidelines to assist with imaging referrals.

IntroductionKnife crime in the United Kingdom remains a leading cause of death (table 1), particularly in the younger population. 259 deaths due to stabbing were recorded year ending March 2019.1Watford...

Point of care simulation in the Emergency Department is a valuable educational tool, with a growing body of evidence supporting the use of simulation in this context. However, a weakness of simulation, even when using high fidelity mannequins, is a lack of realism. This is particularly true in relation to human factors and communication skills. We suggest that using a live, simulated patient during point of care simulation may help overcome this barrier and enhance the learning experience. We developed and delivered a six month point multi-disciplinary point of care simulation programme in the Emergency Department of the Royal Cornwall Hospital, Truro, UK, utilising live clinically trained actors rather than mannequins where possible. Feedback obtained from Emergency Department doctors using a visual analouge scale showed that learners felt this was a positive experience that improved realism and the offered a superior learning experience for non technical skills / human factors. The majority of learners felt that mannequins were superior for learning procedural skills, and valued their use alongside the live actors. In addition, current evidence suggests that curriculum mapping and awareness of learning objectives optimises learning in medical education. Anonymous feedback from within our Emergency Department suggests a low level of learner familiarity with the Emergency Medicine Curriculum, and particularly how this relates to specific simulation scenarios. We created a comprehensive curriculum map for all the simulation scenarios in the six month programme, linking each simulation to specific learning objectives in the Royal College of Emergency Medicine Curriculum. Feedback from Emergency Medicine trainees in our department suggested that running a simulation while utilising a specific curriculum map increases learner awareness of learning objectives and is valued by trainees. In conclusion, we found that by incorporating live patient actors and curriculum mapping into Emergency Department Point of Care Simulation, the learning experience, level of realism and familiarity with the Emergency Medicine curriculum can all be enhanced. By using live actors alongside mannequins for procedural skills, both technical and non technical skills can be optimised.

Introduction The emergency department (ED) is a high risk working environment with clinical and operational protocols in place to attenuate the risks for doctors new to the ED. We implemented a structured direct observation program for new ED doctors who were not Emergency Medicine trainees. Method An ED consultant observed each new ED doctor directly over two weeks without intervention in the clinical encounters. A structured form documented the doctor's performance in pre-defined areas relevant to patient care as well as mastery of operational procedures. Individual strengths and weaknesses were noted. Feedback was provided at the end of each session. After two weeks, the doctors completed a survey form with questions pertaining to their perceived level of competence in areas related to patient care and their experience with the direct observation program. Results There was an overall improvement in their perceived levels of competence in most areas pertaining to patient care. Most felt that this program was useful. Only a minority found it stressful. None felt that it was a waste of time. Conclusion Implementation of direct observation as a focused teaching tool is well received by both junior doctors and Emergency physicians. It provides early insight and feedback into the strengths and weaknesses of the junior doctors and helps new ED doctors to adapt quickly to the work process of the ED.

This study aimed to describe the knowledge, attitudes and practices of emergency department (ED) doctors regarding regional analgesia (RA) for hip fractures and to compare these across levels of experience. A prospective, multicentre survey-based cross-sectional study. Surveys were collected at the EDs of three university-affiliated hospitals in Johannesburg, South Africa. 80 surveys were collected. Participants included all ED doctors. Doctors completing their internship years were excluded. The primary objectives of this study were to describe the knowledge, attitudes and practices of participants regarding the use of RA in hip fractures in the ED; to compare these across different levels of experience based on age, rank and number of years working in the ED; to describe perceived barriers to its use and to describe the frequency of RA use for hip fracture among participants. Thirty-nine per cent of respondents reported having received hip fracture-specific RA training, of whom 52% felt adequately prepared. Knowledge scores (median, IQR) were low for single best answer questions (50%, 39-67) and complications (50%, 38-75), but higher for contraindications (83%, 67-100) and indications (75%, 50-100). Attitudes were broadly positive: 93% viewed RA as safe and effective, and 88% felt all ED doctors should be proficient. Training was mostly informal (94%), predominantly via bedside teaching from an emergency medicine colleague (65%). RA for hip fractures was underused, with 39% reporting never performing it and 27% reporting seldom use. The most cited barrier was a lack of skills (49%), which decreased with increasing ED experience (p=0.012). Despite self-reported generally strong positive attitudes towards RA for hip fractures, it remains underused. Insufficient skills and training were the most common self-reported barriers. Future research could be aimed at assessing the impact of standardised training and departmental protocols on clinical practice.

To assess the level of all-hazards disaster preparedness and training needs of emergency department (ED) doctors and nurses in Hong Kong from their perspective, and identify factors associated with high perceived personal preparedness. This study was a cross-sectional territory-wide online survey conducted from 9 September to 26 October, 2015.ParticipantsThe participants were doctors from the Hong Kong College of Emergency Medicine and nurses from the Hong Kong College of Emergency Nursing. We assessed various components of all-hazards preparedness using a 25-item questionnaire. Backward logistic regression was used to identify factors associated with perceived preparedness. A total of 107 responses were analyzed. Respondents lacked training in disaster management, emergency communication, psychological first aid, public health interventions, disaster law and ethics, media handling, and humanitarian response in an overseas setting. High perceived workplace preparedness, length of practice, and willingness to respond were associated with high perceived personal preparedness. Given the current gaps in and needs for increased disaster preparedness training, ED doctors and nurses in Hong Kong may benefit from the development of core-competency-based training targeting the under-trained areas, measures to improve staff confidence in their workplaces, and efforts to remove barriers to staff willingness to respond. (Disaster Med Public Health Preparedness. 2018; 12: 329-336).

The need to maintain quality and build capacity for emergency medicine training

Are international medical graduates well supported by the emergency medicine community in Australasia? Yes.

Emergency Medicine (EM) clinical pharmacy services are an increasingly widespread practice globally and have been shown to improve patient safety and care in the high-risk environment of the emergency department (ED). However, limited information is published on the implementation barriers and facilitators of these services. This study assessed the current needs of ED doctors and nurses in Singapore General Hospital (SGH) and evaluated their perceptions towards EM clinical pharmacy services. Barriers and facilitators to the implementation of these services in the new SGH EM building were further explored. An anonymous survey was sent to all SGH ED doctors and nurses to assess their perceptions towards EM clinical pharmacy services. Qualitative data on barriers and facilitators were explored through open-ended questions in the survey and semi-structured interviews. Qualitative data were analysed via thematic analysis using the Consolidated Framework of Implementation Research. A total of 205 survey responses were collected, and seven interviews were conducted. The top-ranked services identified were drug information consultation, facilitating timely treatment of emergency conditions, and providing staff and patient education. Pertinent barriers to the implementation of the services comprised cost, culture, compatibility, and staffing. Key facilitators included the relative advantage of the services, tension for change within SGH ED, tailoring strategies, and engaging doctors and nurses during the implementation process. ED doctors and nurses favourably perceived EM clinical pharmacy services. Strategies to implement the services should be tailored to address barriers and leverage facilitators identified for successful implementation within the local ED context.

Science fiction movie fans will already be familiar with one possible future for emergency medicine education and training. In the 1999 film The Matrix (Warner Bros.® Entertainment) Keanu Reeves's character Neo simply connects to a computer via a port in the back of his head and receives a ‘direct download’ of knowledge and skills ranging from martial arts and bullet dodging to languages (enabling him to save the world, obviously). The experience appears briefly painful but incredibly efficient. But is this really the right way to acquire the knowledge and skills required for a 21st century emergency physician? Can an efficient ‘direct download’ ever capture the science and art of our practice? Approaches to undergraduate medical education in the USA were shaped by the Flexner reforms in the early 20th century and were largely responsible for the current structure of most Western medical schools, with preclinical learning phases followed by apprenticeship based clinical rotations. ‘Emergency medicine’ does not appear as a distinct curricular area within these medical schools, which were generally structured according to the pathological basis of disease. It was the establishment of emergency medicine as a specialty – with dedicated EDs and staff – that required the development of specific training programmes. This occurred in the early 1970s in the USA and similar developments occurred in Australasia, Canada and the UK over the next 10–20 years. Prior to this, staff in Australasian EDs had generally trained in other specialties – surgery, general practice, or medicine – or were pre-vocational doctors. The story of the ACEM training programme for emergency medicine specialists is impressive. A curriculum and training programme was developed with a similar structure, duration and examination system to the other specialist medical colleges. The first Primary Examination (testing the basic sciences of anatomy, pathology, physiology and pharmacology) was first conducted in 1984. The first Fellowship Examination, a six-part clinical exit examination, was held in 1986 with eight successful candidates.4 Since the establishment of the college training programme, more than 1000 Fellows have graduated. There has been maturation of training processes, curriculum and assessment, and development of robust systems of accreditation of EDs for training. The current Curriculum Revision Project5 promises a significant renewal of curricular objectives and of training and assessment processes. The scope of clinical knowledge and skills required for physicians working in emergency medicine is broad and overlaps with most other specialty areas. Following the general trend in medical education, emergency medicine training now also explicitly includes ‘professional’ domains of learning, including communication, leadership, ethics, teamwork, management and system-based practice. These domains remain underrepresented in teaching activities and in assessment, despite their critical importance in contemporary practice. So what does a contemporary emergency medicine training program in 2013 look like? How close are we to a ‘direct download'? Accredited EDs also offer structured teaching to support workplace experience. This includes large and small group teaching, journal clubs, procedural skills training and simulation, online learning and a variety of other innovative formats. Most trainees also augment this learning with external resources, including Social Media, FOAM7 and dedicated workshops for skills, such as ultrasound. Assessment drives learning in every educational programme, and the emergency trainees' focus is often on passing exams. Independent specialist examinations were an early signal of emergency medicine's credibility as a specialty in Australasia. The adoption of rigorous psychometric analysis of examinations and of workplace based assessment in emergency medicine are typical of the broader evolution in assessment in medical education. But are these advances in educational approach enough? Do our ED patients have better outcomes and experiences than they did prior to 1986 when our first Fellows by examination graduated? Alternatively – are our techniques also wrong? Have we ‘over-codified’ our emergency medicine science and art? Does the competency approach fail to include the tacit elements of our expertise? Those science fiction film fans will also be familiar with this alternative future for emergency medicine education and training. In the 1980 Star Wars sequel The Empire Strikes Back (Lucasfilm® Ltd), we follow Luke Skywalker's struggle as a trainee Jedi Knight. There are no books, no podcasts, no lectures and no assignments – simply a ‘clinical immersion’ on the planet of Dagobah, under the apprenticeship of Yoda, a Jedi Master. The training and the Master are tough. Yoda has high (but clear) expectations. He is prepared to support but not spoon feed and makes it clear that life and death will be outcomes related to Luke's competence… . ‘No. Try not. Do, do. Or do not. There is no try’.9 The future challenges for which this education is preparing him for are not clear – there will not be easy recipes, but there will be best practice, core principles and a need for flexibility and adaptability. Sometimes Luke fails his challenges, sometimes he succeeds. Perhaps most importantly, when Luke leaves planet Dagobah after his training, he is under no delusion that he is finished his education… . None declared.

In recent years, attrition from Emergency Medicine (EM) training in Ireland has increased. Australian data illustrates that increasing numbers of Irish-trained doctors are embarking on EM training in Australia. This has implications for EM in Ireland, particularly for Emergency Departments already under strain. An adequate supply of qualified specialist EM doctors is essential to provide high-quality patient care. The aim of this study is to gain insights into the reasons for attrition from EM training in Ireland. EM trainees who exited EM training in Ireland 2011-2016 were invited to complete a survey which included quantitative and free-text questions. Of 43 doctors who had exited EM training, 71% responded and although some respondents spoke positively about the speciality, overall, their feedback illustrated levels of frustration and dissatisfaction with EM trainingin Ireland. Respondents exited their EM training programme due to a lack of training received, despite being formally registered on anIrish EM training scheme. The other factors raised included dissatisfaction with the general working conditions in EM in Ireland with respondents highlighting heavy workloads, high work intensity, stress, staff shortages, and poor work-life balance. Our findings indicate the need to improve training and working conditions in Emergency Medicine in Ireland. These improvements are necessary to reduce attrition and improve retention of EM staff.

Introduction:In 2019 the Royal College of Emergency Medicine released a SL0 6 curriculum requirements outlining several procedural skills required for emergency medicine [1]. This key emergency skills are recognised as time critical and/or life or limb saving. The skill set for these tasks is appropriate for a simulated environment and exposure to task via a mastery learning simulation and repeated deliberate practice throughout training and after. These skills include resuscitative hysterotomy, lateral canthotomy, pericardiocentesis and front of neck access.Methods:The Acute School in the North East runs a dedicated HALO simulation training day as part of the regional teaching programme day has a region wide faculty including emergency medicine consultants and speciality consultants. There are 8 procedural skill and 2 simulation scenario stations. To meet the large classroom capacity and the two simulation suites/staff required, the day utilises the MELISSA (Mobile Education Learning Improving Simulation Safety Activity) bus [2]. The skills stations use a combination of procedure specific task trainers, a haptic perimortem C-section trainer (C- Celia) and 3d printed task trainers for lateral canthotomy. Surveys are sent to trainees prior to the course to ascertain training years for group allocations and an evaluation survey containing Likert and qualitative statements conducted after the session.Results:There were 32 trainees in attendance in 1st year, 49 in the 2nd year, representing 60% of trainees in the programme in the first year with 75% in the second year of running (trainees on full 24 hours rotas so not required to attend on night shift and annual leave commitments). The overall course evaluated highly with all stations receiving >90% good or very good scores. The maternal cardiac arrest simulation averaged 4.88/5 scores and the front of neck access facial trauma simulation 4.90/5 score. The stations with specialists received more very good evaluations.Discussion:The HALO training day is now a fixed training day within the emergency medicine training programme in the northeast and north Cumbria. The attendees and faculty evaluate the day highly, with repeat requests to participate from faculty. Anecdotally, the maxillary-facial seniors have reported more lateral canthotomies being performed by Emergency Department doctors rather than referral since the first course. The success of the course has resulting in an expansion to training days for locally employed doctors and emergency medicine consultants in the region for 2025.Ethics statement:Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

The Council of Emergency Medicine Residency Directors (CORD) introduced the standardized letter of recommendation (SLOR) in 1997, and it has become a critical tool for assessing candidates for emergency medicine (EM) training. It has not itself been evaluated since the initial studies associated with its introduction. This study characterizes current SLOR use to evaluate whether it serves its intended purpose of being standardized, concise, and discriminating. This retrospective, multi-institutional study evaluated letters of recommendation from U.S. allopathic applicants to three EM training programs during the 2011-2012 Electronic Residency Application Service (ERAS) application cycle. Distributions of responses to each question on the SLOR were calculated, and the free-text responses were analyzed. Two pilots, performed on five applicants each, assisted in developing a strategy for limiting interrater reliability. Each of the three geographically diverse programs provided a complete list of U.S. allopathic applicants to their program. Upon randomization, each program received a list of coded applicants unique to their program randomly selected for data collection. The number of applicants was selected to reach a goal of approximately 200 SLORs per site (n = 602). Among this group, comprising 278 of 1,498 applicants (18.6%) from U.S. allopathic schools, a total of 1,037 letters of recommendation were written, with 724 (69.8%) written by emergency physicians. SLORs represented 57.9% (602/1037) of all LORs (by any kind of author) and 83.1% (602/724) of letters written by emergency physicians. Three hundred ninety-two of 602 SLORs had a single author (65.1%). For the question on "global assessment," students were scored in the top 10% in 234 of 583 of applications (40.1%; question not answered by some), and 485 of 583 (83.2%) of the applicants were ranked above the level of their peers. Similarly, >95% of all applicants were ranked in the top third compared to peers, for all but one section under "qualifications for emergency medicine." For 405 of 602 of all SLORs (67.2%), one or more questions were left unanswered, while 76 of all SLORs (12.6%) were "customized" or changed from the standard template. Finally, in 291 of 599 of SLORs (48.6%), the word count was greater than the recommended maximum of 200 words. Grade inflation is marked throughout the SLOR, limiting its ability to be discriminating. Furthermore, template customization and skipped questions work against the intention to standardize the SLOR. Finally, it is not uncommon for comments to be longer than guideline recommendations. As an assessment tool, the SLOR could be more discerning, concise, and standardized to serve its intended purpose.

Failure to assess adequately a patient's capacity to refuse treatment may have serious medicolegal consequences Increasing numbers of patients attend the accident and emergency department after an episode of deliberate...

BackgroundThere are many physical, mental and social complications of fatigue associated with working shifts. Emergency Medicine is experiencing a crisis within the UK with a low recruitment rate and a...