Initial Practice Patterns of Physician Assistants With Emergency Medical Services Experience

This study explores the value of Emergency Medical Services (EMS) experience for students applying to medical school. Surveys were sent to 67 medical schools in the eastern United States and Canada. Using a five-point Likert scale, the survey asked the respondent to rate the amount of consideration given to Emergency Medical Technician (EMT) or paramedic experience when making admissions decisions (1 = very little to 5 = strong), and to describe the influence of that experience (1 = very negative to 5 = very positive). Usable responses were received from 21 schools. The median rating for the consideration given to EMS experience was "some consideration" for both EMT and paramedic experience, with 85.7% of respondents assigning that rating or higher. The median rating for the influence of that experience was "somewhat positive" for both EMT and paramedic experience. Only 14.3% of the returned surveys rated EMS experience as "neutral", and no respondent reported EMS experience as a "negative". EMS experience receives at least some consideration during the admissions process at most of the responding institutions in the United States and Canada. Experiences at either the EMT or Paramedic level are viewed similarly. None of the responding institutions viewed EMS experience negatively.

Are NP Week Celebrations Good for NPs?

Introduction: Emergency medical services (EMS) are a critical component to Emergency Medicine (EM) residency training. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) has established minimum training requirements for EM residency programs. Since the last study exploring resident EMS involvement was performed, there have been over 100 new EM resident programs started. Given the rapid increase in new EM programs, we sought to determine EMS experiences provided to current EM residents. Materials and Methods: A 22-question anonymous online survey was distributed through E-mail to program directors of approved EM residencies in October 2020. A follow-up reminder was sent 3 weeks later. Results: In total, 51 of 257 programs responded (20% response rate). Forty-five percent of EM residents experience between 10 and 25 EMS calls during their residency, 31% experience 26–50, and 20% experience >50 calls. The majority of programs (53%) have a separate EMS rotation where residents function as observers, 24% of residents function as providers, and 25% also have residents respond in a dedicated physician response vehicle. Aeromedical exposure is limited (47% have none and 43% average only 1–9 flights). Two-thirds of programs (67%) have residents provide online medical command during their ED shifts and 61% require residents to provide didactics to EMS clinicians. Despite ACGME requirements, only two-thirds of programs (69%) provide training about disaster/mass casualty incident (MCI) management and 67% have them participate in a disaster/MCI drill. About one-third of programs (31%) have decreased EMS experiences due to limited time in the residency curriculum, and 20% of programs have limited EMS experiences due to the COVID pandemic. Conclusions: The majority of responding EM residency programs meet ACGME EMS-related requirements. There is an opportunity for improvement around disaster education based on these data. Limited time in the curriculum and the COVID pandemic were cited as reasons that programs have limited their EMS experiences. The following core competencies are addressed in this article: Practice-Based Learning and Improvement, Medical Knowledge.

The objective was to evaluate the efficacy of a required emergency medicine (EM) experience embedded in a new community-based longitudinal integrated clerkship (LIC) for participating students and faculty. We developed and implemented a community-based LIC EM experience. The experience included 10 clinical shifts, one emergency medical services prehospital care shift, four didactic sessions, one reflection, and an emergency medicine simulation session. Students' outcomes were assessed using end-of-year surveys, focus groups, an emergency medicine subject examination, simulation performance, and clinical evaluations of the students by faculty. Faculty were recruited, underwent faculty development, and were evaluated by students. Faculty perceptions were gathered from a focus group and faculty retention rates were collected. Three cohorts of LIC students (total N=61) have completed their core emergency medicine experience in our community-based LIC. Among students, 76% to 95% rated the overall quality of teaching as very good or excellent and 66% to 100% rated the quality of learning in their community-based setting as very good or excellent. All students who passed the EM subject examination achieved the clinical competencies of the experience based on clinical evaluations. Among faculty, we have retained greater than 95% each year and they have reflected positively on their precepting experience. Implementing a required EM experience within a community-based LIC model can be an effective learning experience for students and perceived positively by community-based faculty. This model may offer an opportunity to expand clinical learning experiences in EM.

Introduction: One of the six guiding principles of the EMS Agenda 2050 is to foster a socially equitable care delivery system. A specific recommendation within this principle is that “local EMS leadership, educators and clinicians [should] reflect the diversity of their communities.” Research has shown that women comprise a minority of emergency medicine services (EMS) field clinicians. In academic settings, women are represented at lower rates among experienced EMS faculty than within Emergency Medicine clinicians or faculty at large. The reasons for these differences are also unknown. Little data exist describing the number or experience of female physicians and professionals in EMS. Purpose: Our objective was to describe the composition and experiences of EMS physicians, researchers and professionals who participate in the Women in EMS group of the National Association of EMS Physicians (NAEMSP). Methods: We performed a cross-sectional, mixed-methods descriptive study of women belonging to the Women in EMS Committee of NAEMSP. A survey was sent to the 143 members of this group using a list-serve, and the data was collected in Redcap. Results: Seventy-four people completed the survey. Respondents were 96% female, 82% Caucasian, 11% underrepresented minorities (URM), and 7% LGBTQI. Of the 88% that are physicians, 78% are board certified in Emergency Medicine, compared to 55% in EMS. Forty-eight percent reported they received some form of mentorship. Among these respondents, a minority reported female mentorship, which was usually from a remote rather than local mentor (41% vs. 15%). Eighty-three percent of respondents had experienced some form of discrimination or harassment in their career, but only 68% reported their workplace culture discourages such behavior. Thirty-three percent of respondents report receiving unequal recognition because of gender. Thematic evaluation of the qualitative responses showed that respondents felt there were fewer barriers to mentorship and professional advancement opportunities in local work versus national engagement. Conclusions: In a survey evaluating representation of female professionals in EMS, participants reported on their career representations, and experiences of gender-based inequity within their EMS career settings. Several opportunities exist to improve diversity, equity, and inclusion for women in EMS based on our findings.

Injury care is a core part of daily emergency medicine (EM) clinical practice, accounting for over one-third of emergency department (ED) visits every year.1 It also remains a formidable burden to the public’s health in the United States. The Centers for Disease Control and Prevention (CDC) reports that in 2006, 179,065 Americans died as a result of injury,2 and in 2007, 29,756,586 suffered nonfatal injuries.3 Historically, the development of the science of injury prevention and control has paralleled the evolution of the specialty of EM. This was initially nested within the context of emergency medical services (EMS) and trauma systems development. In the 1966 landmark publication, Accidental Death and Disability: The Neglected Disease of Modern Society, the National Academy of Sciences and the National Research Council detailed the first examination of the country’s burden of injury morbidity and mortality. The report outlined specific recommendations calling for EMS development and meaningful federal agency guidance and oversight.4 Along with the first federal funding to establish EMS in the late 1960s and early 1970s came the establishment of the National Highway Safety Bureau (later known as the National Highway Traffic Safety Administration [NHTSA]). This emphasis on EMS contributed to the development and organization of EDs and specialty training of emergency physicians (EPs). As the specialty of EM began to grow in the 1970s, the public’s awareness of the continued high injury-related morbidity and mortality statistics raised the urgency for policy-makers to address the nation’s injury burden. As a result, state and federal health officials and researchers began to focus their efforts on population health to accurately describe and formulate plans to address the injury burden and its impact on U.S. communities. In 1985, the first of the landmark “red books,”Injury in America: A Continuing Public Health Problem, was published.5 This report outlined the magnitude of the national injury burden, and the gaps in addressing this burden comprehensively, and provided descriptions of opportunities for medical specialties to participate in reducing this burden. Subsequent national reports6 continued to reveal the cost of injury and the challenges in addressing this public health burden. Simultaneously, EM as a specialty began to build its intentional and positive influence in the future development of injury prevention and control activities and science. Over the past two and a half decades, EM’s efforts to address injury as a public health burden have led many EPs to engage in injury prevention and control activities through participation and leadership in surveillance and research, education, and advocacy. These collective efforts have fostered growth in the body of knowledge of injury science and have helped to lessen the burden on society. As the clinical specialty treating the entire spectrum of injury occurring in children and adults, EM is uniquely positioned to contribute to the science of injury prevention and control. At a population level, EM is able to provide understanding of types of injury patterns occurring, the risk factors for their occurrence, and the outcome of the injury. In creating epidemiologic profiles of injury patterns, interventions at both the individual and the population level can be developed and examined. Within states, EM contributes to injury surveillance with external cause coding (E-codes) in the hospital ED data system. Although these data are used primarily for administrative and billing purposes, they provide important state-level external cause of injury data for measuring the impact of nonfatal injury in that state, allowing policy-makers to make data-driven decisions regarding injury prevention.7 Several large national databases that utilize ED data on injured patients are frequently accessed and used by researchers both within and outside of EM to describe a specific injury problem and discuss mechanisms for prevention and control. One database that relies solely on ED data is the National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP), which is a collaborative effort between the US Consumer Product Safety Commission and the CDC’s National Center for Injury Prevention and Control.8 Data on injury-related visits are obtained by NEISS-AIP from a national stratified probability sample of hospitals in the United States and its territories with a minimum of six beds and a 24-hour ED. NEISS-AIP collects data on initial visits for all categories of injuries treated in U.S. EDs and provides data on nearly 500,000 injury-related ED visits annually. Not only does EM contribute to the database through its clinical work, but researchers within the specialty have been consumers of the data and utilize it to further describe injury patterns.9–11 Another injury surveillance database that EM contributes to is the Crash Outcome Data Evaluation System (CODES) database that is maintained by NHTSA.12 It is a statewide population-based probabilistic linkage of police reports on motor vehicle crash (MVC), EMS, and hospital/ED data. EM researchers have used this database in describing transportation injury problems.13,14 Emergency physicians now lead many regional poison control centers. These centers provide important toxicologic expertise for patient care, as well as a large amount of data on the occurrence and outcomes of poisonings that is utilized by EM and non-EM researchers.15,16 The Drug Abuse Warning Network (DAWN)17 is a public health surveillance system that monitors drug-related visits to EDs and helps communities identify emerging problems that are risk factors for intentional and unintentional injuries. EM-based injury prevention research has also had a substantive role with both interventional and translational research at the patient care level and advancing clinical preventive services. One example is EM-based randomized clinical trials in the area of screening, brief intervention, and referral to treatment (SBIRT) for alcohol use disorders that have demonstrated decreased alcohol use,18 injury,19 or risky behaviors for injury occurrence.20 This has led to type II translational research21 (bedside to community) on how to best integrate SBIRT into routine EM care.22 The ED is frequently a treatment site for victims of interpersonal violence. This has allowed EM-based researchers to contribute to the knowledge development of this problem, as well as expand research to better screen for and intervene with victims.23–25 Motor vehicle crashes are the leading cause of injury death in the first three decades of life. Caring for the entire spectrum of MVC trauma victims allows EM to develop research foci in this area of testing and interventions to decrease future injury risk26 and contributing to the clinical research of care of the injured trauma patient to prevent secondary injury. It has also allowed EM to contribute to the science involving the biomechanics of crash injury27,28 and an appropriate EMS response to reduce the occurrence of secondary injury.29,30 As a result of growing interest and leadership in injury prevention and control, several departments of EM began to organize their efforts and form injury prevention centers. These centers have had a research focus, but also have efforts directed at injury prevention education and community programs. The growing number of EM-led centers reflects the increased leadership that the specialty brings to the field of injury prevention and control. These centers31–35 have a track record of state and federal research funding for injury prevention and control research, as well as incorporating missions for education and community outreach. Several offer fellowship training in injury prevention and control for EM trainees. Instruction to EM residents on injury prevention was first addressed in 1990,36 with a short course with the goal to “provide information on motor vehicle crashes in a public health framework.” As others in EM began to publish and lecture on this topic, efforts to increase health care professional training in injury prevention increased.37 The Institute of Medicine (IOM) report “Who Will Keep the Public Healthy” noted the importance of injury prevention and control education for the well-being of the population and called for health care professional training programs to make injury prevention training a higher priority.38 EPs in training shared the same belief as the IOM and wanted more injury prevention and control education in their training. In one study, 97% of EM residents in California surveyed between 1992 and 1993 felt that injury prevention was a critical aspect of their work, and 70% felt that it was a necessary focus in their training.39 Many articles and efforts from national organizations, such as the Association of American Medical Colleges, have called for an incorporation of injury prevention and control into medical school curricula40,41 and further advancement into medical training programs, including EM. The integration of injury prevention and control and EM practice and training has continued to grow. Injury prevention and control is now recognized as integral to EM residency training, although it still needs more emphasis in the core curriculum. Medical schools are increasingly recognizing the opportunity injury has in integrating basic science, clinical care, and population health sciences for their students. There are EM-based injury control and prevention fellowships, complementing the traditional trauma surgery fellowships that exist at many academic health centers in the United States. It is important to emphasize the opportunity that EM has to advance the science of injury prevention and control and bring the various injury control stakeholders together. A good example of this can be found in the context of toxicology and poisonings. Acute injury from chemical agents continues to be a growing and significant cause of mortality and morbidity. It is now the leading cause of injury death in Americans age 35–44 years.2 EM already plays a significant national leadership role in toxicology and poison center activities. According to the American College of Emergency Physicians, there are currently more than 20 fellowships in EM toxicology. Emergency medicine leaders in disaster preparedness and response from all physical agents including chemical are also in a strong position to reduce fragmented responses and further improve our overall disaster preparedness by unifying response principles and integrating the science of injury prevention and control. The acute care research agenda of the CDC’s National Center for Injury Prevention and Control calls for case studies that further inform our abilities to address mass casualties from physical agents.42 Among the central goals of training future EM leaders, and in unison with Accreditation Council for Graduate Medical Education (ACGME) principles that guide our resident training43 is the development of professionalism and duty to society in EM trainees.44 Consistent with this, EPs have moved to purposely teach and lead by example as advocates for primary injury prevention and control programs and policies. EM leaders have also organized to educate the community and conduct important policy-relevant injury research expertise. Today, state and federal government agencies continue to seek support from EPs to provide important insights and expertise into injury-related issues that are affecting the nation. EM leaders have made and continue to make substantial contributions within these federal agencies including the CDC, the NHTSA, the Department of Health and Human Services, and the Health Resources and Services Administration. While there has been significant growth in both injury prevention and control science and EM over the past several decades, the current challenges to EM outlined in recent IOM reports45–47 appear to be daunting and potential indicators of a downturn. However, some of these same challenges reveal tangible opportunities for continued parallel growth in injury prevention and control science and EM. One of the most notable areas where such opportunity exists is within the National Institutes of Health’s creation of the Clinical and Translational Science Awards (CTSA). Understanding that each CTSA will have to be understood in its respective institutional culture and context, opportunities for collaboration and EM investigator–initiated training and research in injury prevention and control should exist. Training EPs in translational sciences has the potential to significantly enhance the capacity for future EM researcher and specialty success while advancing the science of injury prevention and control. The development and growth of injury prevention and control science and EM as a medical specialty have had paralleled success. The spectrum of leadership of EPs in injury prevention began at the bedside with the desire of EPs to deliver the very best care to injured patients. Many EPs and departments have gone beyond the doors of the ED and have been instrumental in influencing important systems of surveillance, clinical care, and health policy so that primary and secondary prevention efforts are effectively developed and implemented. Still other EPs have gone further to champion injury prevention and control in a variety of prominent leadership positions at state and federal levels. Injury research centers, with primary and collaborative EM leadership, continue to flourish nationally, with EPs partnering with colleagues in surgery, pediatrics, psychiatry, epidemiology, and other disciplines on injury research, advocacy, and policy. The future of EM leadership and growth in injury prevention and control science remains promising, with opportunities for the development and execution of robust research that will influence the public’s health in meaningful and measurable ways.

International EMS Systems: the Nordic countries.

The assessment of clinical competence on the emergency medicine specialty certification examination: The validity of clinically relevant multiple-choice items

Spain has universal public health care coverage. Emergency care provisions are offered to patients in different modalities and levels according to the characteristics of the medical complaint: at primary care centers (PCC), in an extrahospital setting by emergency medical services (EMS) and at hospital emergency departments (ED). We have more than 3,000 PCCs, which are run by family doctors (general practitioners) and pediatricians. On average, there is 1 PCC for every 15,000 to 20,000 inhabitants, and every family doctor is in charge of 1,500 to 2,000 citizens, although less populated zones tend to have lower ratios. Doctors spend part of their duty time in providing emergency care to their own patients. While not fully devoted to emergency medicine (EM) practice, they do manage minor emergencies. However, Spanish EMSs contribute hugely to guarantee population coverage in all situations. These EMS are run by EM technicians (EMT), nurses and doctors, who usually work exclusively in the emergency arena. EDs dealt with more than 25 million consultations in 2008, which implies, on average, that one out of two Spaniards visited an ED during this time. They are usually equipped with a wide range of diagnostic tools, most including ultrasonography and computerized tomography scans. The academic and training background of doctors working in the ED varies: nearly half lack any structured specialty residence training, but many have done specific master or postgraduate studies within the EM field. The demand for emergency care has grown at an annual rate of over 4% during the last decade. This percentage, which was greater than the 2% population increase during the same period, has outpaced the growth in ED capacity. Therefore, Spanish EDs become overcrowded when the system exerts minimal stress. Despite the high EM caseload and the potential severity of the conditions, training in EM is still unregulated in Spain. However, in April 2009 the Spanish Minister of Health announced the imminent approval of an EM specialty, allowing the first EM resident to officially start in 2011. Spanish emergency physicians look forward to the final approval, which will complete the modernization of emergency health care provision in Spain.

Conducted electrical weapons (CEWs), including Thomas A. Swift Electric Rifles (TASERs), are increasingly used by law enforcement officers (LEOs) in the US and world-wide. Little is known about the experience of Emergency Medical Service (EMS) providers with these incidents. This study describes EMS encounters with documented TASER use and barb removal, characteristics of resulting injuries, and treatment provided. This retrospective study used five combined, consecutive National Emergency Medical Services Information System (NEMSIS; Salt Lake City, Utah USA) public-release datasets (2011-2015). All EMS activations with documented TASER barb removal were included. Descriptive analyses were carried out. The study included 648 EMS activations with documented TASER barb removal, yielding a prevalence rate of 4.55 per 1,000,000 EMS activations. Patients had a mean age of 35.9 years (SD=18.2). The majority were males (80.2%) and mainly white (71.3%). Included EMS activations were mostly in urban or suburban areas (78.3%). Over one-half received Advanced Life Support (ALS)-level of service (58.2%). The most common chief complaint reported by dispatch were burns (29.9%), followed by traumatic injury (16.1%). Patients had pain (45.6%) or wound (17.2%) as a primary symptom, with most having possible injury (77.8%). Reported causes of injury were mainly fire and flames (29.8%) or excessive heat (16.7%). The provider's primary impressions were traumatic injury (66.3%) and behavioral/psychiatric disorder (16.8%). Only one cardiac arrest (0.2%) was reported. Over one-half of activations resulted in patient transports (56.3%), mainly to a hospital (91.2%). These encounters required routine EMS care (procedures and medications). An increase in the prevalence of EMS activations with documented TASER barb removal over the study period was not significant (P=.27). At present, EMS activations with documented TASER barb removal are rare. Routine care by EMS is expected, and life-threatening emergencies are not common. All EMS providers should be familiar with local policies and procedures related to TASER use and barb removal.El SayedM, El TawilC, TamimH, MailhacA, MannNC. Emergency Medical Services experience with barb removal after TASER use by law enforcement: a descriptive national study. Prehosp Disaster Med. 2019;34(1):38-45.

An attempt was made to determine the extent to which physicians trained and certified in family medicine are involved in emergency medicine. An 18-item, self-report questionnaire was mailed to 73 graduates of a family practice residency program to obtain information on their practices, their professional and emergency medicine experiences, and their attitudes toward the practice of emergency medicine by family practitioners. Ten percent of the 60 responding physicians were currently involved in full-time emergency medicine in either emergency rooms or minor emergency clinics. Twenty-eight percent of the respondents were currently practicing emergency medicine on either a part-time or sporadic basis. Supplemental income was cited the most often as a reason for becoming involved in emergency medicine. Only variables related to the physicians' attitudes discriminated between those who were practicing emergency medicine and those who were not.

Introduction: Practicing emergency medicine (EM) involves rapid decision-making in an acute setting, broad knowledge and a strong ability to multi-task. Some medical students find these characteristics attractive, while others find them a deterrent. Previous studies have indicated the range of characteristics that interest undergraduate students. No studies have followed students to assess how attitudes towards EM careers evolve over their schooling. Methods: An open-ended survey of medical students’ career interests was distributed at five data-collection points over the four years of undergraduate training from 1999-2006 at Memorial University. Guided by principles of grounded theory the qualitative data was coded to identify key themes and sentinel quotes. Semi-structured interviews with academic emergency physicians at Dalhousie University were then conducted to assess the relevance of these findings to postgraduate training (in progress). These transcripts were analyzed in the same manner as the longitudinal surveys. Results: 1281 surveys were completed by 540 students, with 758 comments about EM. The biggest drawbacks of EM included lack of patient follow-up and lack of experience in EM; the biggest benefits included variety of cases and patients, congruence with previous life experiences, and elective experiences. One major theme was the Certificant of the College of Family Physicians (CCFP) EM training, as it meant a shorter residency that was more transferrable to rural settings. Lifestyle was a prominent theme, seen as positive by some and negative by others. Emergency physicians commented on students’ naivety, especially relating to media and the nature of the work early in their training. Conclusion: Medical students’ opinions of EM tend to shift throughout their schooling, in particular, the perception of the work. Medical students’ perceptions differ significantly from that of experienced emergency physicians, highlighting the need for a greater degree of mentoring. Perceptions of lifestyle in EM are highly variable amongst students, acting as both a benefit and a drawback. Medical schools may be able to improve clinical exposure and provide more informed career counselling with respect to emergency medicine. Residency program directors can consider these findings during recruitment and interviewing to determine whether students have a realistic view of the specialty and career trajectory.

More Science for the New Subspecialty

Emergency medicine: past, present, and future challenges

BackgroundPodcasts and their use in medical education, particularly emergency medicine (EM), are growing and becoming more popular. Many podcasts focus on EM, but the number of podcasts on each EM subspecialty remains unknown. Therefore, the goal of this study was to ascertain the number of podcasts available by EM subspecialty and collect the basic characteristics of each podcast.MethodsWe conducted a Google-based, investigational study of EM podcasts by subspecialty from July 2019 to January 2020. Search terms included “podcasts in ____”, where the EM subspecialties of Toxicology, Ultrasound, Wilderness Medicine, Emergency Medicine Services, Medical Education, and Simulation were inserted to identify podcasts.Results Emergency Medical Services (EMS) and Medical Education subspecialties have the most active podcasts. Toxicology and EMS have the most inactive podcasts, while Medical Education and Simulation were the only subspecialties found to not have any identified inactive podcasts.ConclusionsThe use of podcasts in EM has been increasing overall, but physicians in specific subspecialties, such as EMS and Medical Education, have access to a larger number of podcasts specific to their subspecialty than others. There is an opportunity for experts in Toxicology, Simulation, and Ultrasound to create podcast content.