Emergency Medicine Skills Research Articles

Giancarlo (Gianni) Berni

Emergency medicine specialist who “taught Italy how to do first aid” Giancarlo (Gianni) Berni, who has died just a few months short of his 80th birthday, is credited with bringing...

Competency-based simulation assessment of resuscitation skills in emergency medicine postgraduate trainees – a Canadian multi-centred study

The use of high-fidelity simulation is emerging as a desirable method for competency-based assessment in postgraduate medical education. We aimed to demonstrate the feasibility and validity of a multi-centre simulation-based Objective Structured Clinical Examination (OSCE) of resuscitation competence with Canadian Emergency Medicine (EM) trainees. EM postgraduate trainees (n=98) from five Canadian academic centres participated in a high fidelity, 3-station simulation-based OSCE. Expert panels of three emergency physicians evaluated trainee performances at each centre using the Queen's Simulation Assessment Tool (QSAT). Intraclass correlation coefficients were used to measure the inter-rater reliability, and analysis of variance was used to measure the discriminatory validity of each scenario. A fully crossed generalizability study was also conducted for each examination centre. Inter-rater reliability in four of the five centres was strong with a median absolute intraclass correlation coefficient (ICC) across centres and scenarios of 0.89 [0.65-0.97]. Discriminatory validity was also strong (p < 0.001 for scenarios 1 and 3; p < 0.05 for scenario 2). Generalizability studies found significant variations at two of the study centres. This study demonstrates the successful pilot administration of a multi-centre, 3-station simulation-based OSCE for the assessment of resuscitation competence in post-graduate Emergency Medicine trainees.

Cross cultural near-peer modules teaching emergency medicine skills and BLS in Haiti: Results and future directions

Cross cultural near-peer modules teaching emergency medicine skills and BLS in Haiti: Results and future directions

Development and assessment of a pediatric emergency medicine simulation and skills rotation: meeting the demands of a large pediatric clerkship

ObjectiveTo implement a curriculum using simulation and skills training to augment a Pediatric Emergency Medicine (PEM) rotation within a pediatric clerkship.BackgroundPEM faculty are often challenged with a high learner to teacher ratio in a chaotic clinical setting. This challenge was heightened when our pediatric clerkship's traditional 1-week PEM rotation (consisting of 4 students completing four 8-hour ED shifts/week) expanded to 8 students every 2 weeks. We sought to meet this challenge by integrating simulation-based education into the rotation.MethodsClerkship students from March to June 2012 completed our traditional rotation. Students between July and October 2012 completed the new PEM-SIM curriculum with 19 hours ED shifts/week and 16 hours/week of simulation/skills training. Pre/post-tests evaluated 1) medical management/procedural comfort (five-point Likert scale); and 2) PEM knowledge (15 multiple-choice questions).ResultsOne hundred and nine students completed the study (48 traditional, 61 PEM-SIM). Improvement in comfort was significantly higher for the PEM-SIM group than the traditional group for 6 of 8 (75%) medical management items (p<0.05) and 3 of 7 (43%) procedures, including fracture splinting, lumbar puncture, and abscess incision/drainage (p<0.05). PEM-SIM students had significantly more improvement in mean knowledge compared to the traditional group (p<0.001).ConclusionsWe have successfully integrated 16 hours/week of faculty-facilitated simulation-based education into a PEM rotation within our clerkship. This curriculum is beneficial in clinical settings with high learner to teacher ratios and when patient care experiences alone are insufficient for all students to meet rotation objectives.

Have "new" methods in medical education reached German-speaking Central Europe: a survey.

BackgroundSimulation-based-training (SBT) in the education of health professionals is discussed as an effective alternative for knowledge and skills enhancement as well as for the establishment of a secure learning environment, for learners and patients. In the Anglo-American region, SBT and simulation and training centers (STC) are numbered as standard for medical training. In German-speaking Central Europe, priority is still given to the establishment of SBT and STC. The purpose of this study was (i) to survey the status quo relating to the existence and facilities of simulation and training centers at medical universities in German-speaking Central Europe and (ii) the evaluation of training methods, especially in the area of emergency medicine skills.MethodsAll public and private medical universities or medical faculties in Germany (36), Austria (4) and German-speaking Switzerland (3) were interviewed. In the survey, information regarding the existence and facilities of STCs and information with regards to the use of SBT in the area of emergency medicine was requested. The questions were partly posed in a closed-ended-, in an open-ended- and in a multiple choice format (with the possibility of selecting more than one answer).ResultsOf a total of 43 contacted medical universities/medical faculties, 40 ultimately participated in the survey. As decisive for the establishment of a STC the potential to improve the clinical-practical training and the demand by students were listed. Obligatory training in a STC during the first and sixth academic year was confirmed only by 12 institutions, before the first invasive procedure on patients by 17 institutions. 13 institutions confirmed the use of the STC for the further training of physicians and care-staff. Training for the acute care and emergency medicine skills in the field of pediatrics, for the most part, occurs decentralized.ConclusionsNew methods in medical training have reached German-speaking Central Europe, but the simulation and training centers vary in size, equipment or regarding their integration into the obligatory curriculum as much as the number and variety of the offering to be trained voluntarily or on an obligatory basis.

Mid‐level providers and emergency care: Let's not lose the force

The progressive rise of ED visits globally, and insufficient numbers of emergency physicians, has resulted in the use of mid-level providers as adjuncts for the provision of emergency care, especially in the US and Canada. Military medics, midwives, aeromedical paramedics, EMT-Ps, flight nurses, forensic nurses, sexual assault nurse examiner nurses--are some examples of well-established mid-level provider professionals who achieve their clinical credentials through accredited training programmes and formal certification. In emergency medicine, however, mid-level providers are trained for general care, and typically acquire emergency medicine skills through on-the-job experience. There are very few training programmes for NPs and PAs in emergency care. The manpower gap for physicians in general, and emergency physicians specifically, will not be eliminated in the reasonable future. Mid-level providers--ENTs, paramedics, NPs, PAs--are an excellent addition to the emergency medicine workforce. However, the specialty of emergency medicine developed because specific and focused training was needed for physicians to practice safe and qualify emergency care. This same principle applies to mid-level providers. Emergency Medicine needs to develop a vision and a plan to train emergency medicine specialist NPs and PAs, and explore other innovations to expand our emergency care workforce.

How and When Do Expert Emergency Physicians Generate and Evaluate Diagnostic Hypotheses? A Qualitative Study Using Head-Mounted Video Cued-Recall Interviews

The ability to make a diagnosis is a crucial skill in emergency medicine. Little is known about the way emergency physicians reach a diagnosis. This study aims to identify how and when, during the initial patient examination, emergency physicians generate and evaluate diagnostic hypotheses. We carried out a qualitative research project based on semistructured interviews with emergency physicians. The interviews concerned management of an emergency situation during routine medical practice. They were associated with viewing the video recording of emergency situations filmed in an "own-point-of-view" perspective. The emergency physicians generated an average of 5 diagnostic hypotheses. Most of these hypotheses were generated before meeting the patient or within the first 5 minutes of the meeting. The hypotheses were then rank ordered within the context of a verification procedure based on identifying key information. These tasks were usually accomplished without conscious effort. No hypothesis was completely confirmed or refuted until the results of investigations were available. The generation and rank ordering of diagnostic hypotheses is based on the activation of cognitive processes, enabling expert emergency physicians to process environmental information and link it to past experiences. The physicians seemed to strive to avoid the risk of error by remaining aware of the possibility of alternative hypotheses as long as they did not have the results of investigations. Understanding the diagnostic process used by emergency physicians provides interesting ideas for training residents in a specialty in which the prevalence of reasoning errors leading to incorrect diagnoses is high.

Effect of applying emergency care simulator on cardiopulmonary resuscitation skill training

Objective To evaluate the effect of applying emergency care simulator （ECS）on cardiopulmonary resuscitation skill training. Methods Clinical doctors and nurses（n=1 472）received the skill training of unarmed cardiopulmonary resuscitation （CPR）,electric defibrillation and tracheal intubation by using simple CPR simulator （n=667）or ECS （n=805）respectively. After training,the examination was carried out and questionnaires were handed out. The completion time of operations, the scores and pass rates of examinations,the evaluations of training methods were compared between the two groups. The statistical data were analyzed by t（t＇）-test or Chi-square test with SPSS 19.0 and P 〈0.05 was considered as the criterion of significance. Results Compared with those of group using simple CPR simulator,the group using ECS showed obviously shortened completion time（（309±125）s vs. （242±61）s,t＇=12.65,P=0.00;（87±36）s vs. （55±31）s,t＇=20.28,P=0.00;（239±87）s vs. （145±53）,t＇=24.4,P=0.00）,significantly increased scores （（83.5±14.8）vs. （90.2±17.6）, t＇=7.93,P=0.00;（84.7±19.3）vs. （92.1±21.5）,t＇=6.95,P=0.00;（81.6±15.3）vs. （89.6±13.5）, t＇=10.53,P=0.00）and pass rates of examinations （84.1%（561/667）vs. 92.5%（745/805）,χ2=25.96, P〈0.01;82.2%（548/667）vs. 91.2%（734/805）,χ2=26.41,P〈0.01;80.8%（539/667）vs. 91.4%（736/805）,χ2=35.48,P〈0.01）as well as higher evaluation of training methods. Conclusions Application of ECS can obviously improve the training effect of CPR and it can be widely popularized in the edu-cation and training of emergency medicine skills. Key words: Emergency care simulator; Cardiopulmonary resuscitation; Clinical skill

Simulation training based on observation with minimal participation improves paediatric emergency medicine knowledge, skills and confidence

ObjectiveSimulation is becoming standard during emergency medicine (EM) training. To determine if observation-based simulation with minimal participation improves knowledge, skill performance and confidence, we created and evaluated 12 paediatric emergency...

Pre‐hospital airway management by non‐physicians in Northern Finland – a cross‐sectional survey

Airway management is an important skill in pre-hospital emergency medicine. The most optimal method depends on the resources and experience of the emergency medical service (EMS) providers. We wanted to study the frequency of occurrence, equipment used, problems experienced and maintenance of skills in pre-hospital airway management by non-physicians. A structured questionnaire consisting of 30 questions was distributed to 383 EMS providers in three hospital districts (population 597,521 and area 147,467 km(2) ) in Northern Finland. The questionnaire was answered by 226 EMS providers and 58.5% (224/383) were included in the final analyses. In all, 82.6% (185/224) of the EMS providers were allowed to perform endotracheal intubation (ETI) and 44.2% (99/224) could perform ETI using sedative agents. The annual mean frequency of using a supraglottic airway device (SAD) was 1.0 (range 0-20, n = 224), for ETI it was 2.0 (range 0-16, n = 185) and for bag-valve-mask ventilation it was 4.3 (range 0-30, n = 223). The mean frequency of drug-assisted ETI was 1.1 (range 0-13, n = 99). Unsuccessful ETI had been experienced by 65.7% (119/181) of the EMS providers. Airway management had been practised in an operating room by 25.9% (56/216) and with a manikin by 81.3% (182/224) of the EMS providers during the past 12 months. Advanced airway management procedures are uncommon for most EMS providers in Northern Finland. Procedures, training in and maintenance of airway management skills should be re-evaluated.

Emergency Medicine in Guyana: Lessons from Developing the Country's First Degree-conferring Residency Program

Introduction:Academic departments of emergency medicine are becoming increasingly involved in assisting with the development of long-term emergency medicine training programs in low and middle-income countries. This article presents our 10-year experience working with local partners to improve emergency medical care education in Guyana.Methods:The Vanderbilt Department of Emergency Medicine has collaborated with the Georgetown Public Hospital Corporation on the development of Emergency Medicine skills followed by the implementation of an emergency medicine residency training program. Residency development included a needs assessment, proposed curriculum, internal and external partnerships, University of Guyana and Ministry of Health approval, and funding.Results:In our experience, we have found that our successful program initiation was due in large part to the pre-existing interest of several local partners and followed by long-term involvement within the country. As a newer specialty without significant local expertise, resident educational needs mandated a locally present full time EM trained attending to serve as the program director. Both external and internal funding was required to achieve this goal. Local educational efforts were best supplemented by robust distance learning. The program was developed to conform to local academic standards and to train the residents to the level of consultant physicians. Despite the best preparations, future challenges remain.Conclusion:While every program has unique challenges, it is likely many of the issues we have faced are generalizable to other settings and will be useful to other programs considering or currently conducting this type of collaborative project.

Assessing Interpersonal and Communication Skills in Emergency Medicine

Interpersonal and communication skills (ICS) are a key component of several competency-based schemata and key competency in the set of six Accreditation Council for Graduate Medical Education (ACGME) core competencies. With the shift toward a competency-based educational framework, the importance of robust learner assessment becomes paramount. The journal Academic Emergency Medicine (AEM) hosted a consensus conference to discuss education research in emergency medicine (EM). This article summarizes the initial preparatory research that was conducted to brief consensus conference attendees and reports the results of the consensus conference breakout session as it pertains to ICS assessment of learners. The goals of this consensus conference session were to twofold: 1) to determine the state of assessment of observable learner performance and 2) to determine a research agenda within the ICS field for medical educators. The working group identified six key recommendations for medical educators and researchers.

Evaluating Educational Interventions in Emergency Medicine

This article presents the proceedings of the 2012 Academic Emergency Medicine consensus conference breakout group charged with identifying areas necessary for future research regarding effectiveness of educational interventions for teaching emergency medicine (EM) knowledge, skills, and attitudes outside of the clinical setting. The objective was to summarize both medical and nonmedical education literature and report the consensus formation methods and results. The authors present final statements to guide future research aimed at evaluating the best methods for understanding and developing successful EM curricula using all types of educational interventions.

Hand Ultrasound: A High-fidelity Simulation of Lung Sliding

Simulation training has been effectively used to integrate didactic knowledge and technical skills in emergency and critical care medicine. In this article, we introduce a novel model of simulating lung ultrasound and the features of lung sliding and pneumothorax by performing a hand ultrasound. The simulation model involves scanning the palmar aspect of the hand to create normal lung sliding in varying modes of scanning and to mimic ultrasound features of pneumothorax, including "stratosphere/barcode sign" and "lung point." The simple, reproducible, and readily available simulation model we describe demonstrates a high-fidelity simulation surrogate that can be used to rapidly illustrate the signs of normal and abnormal lung sliding at the bedside.

Development of a Content Valid Tool for Assessing End-of-Life Communication in Acute Care Settings

Current recommendations throughout the literature require that physicians demonstrate proficiency in handling end-of-life care issues. However, current training and assessment tools are not easily translated to acutely decompensating emergency department patients with whom the practitioner is not familiar. Without these tools, robust assessment of physician performance cannot occur. To develop a content valid instrument to measure the critical care communication skills of emergency physicians in order to facilitate education and assessment of end-of-life communication skills in a time-sensitive acute care setting. A two-step modified Delphi methodology with emergency medicine palliative care subject matter experts was used. First, an extensive review of the literature was conducted to elucidate broad communication domains important to end-of-life care. Next, subject matter experts were asked open-ended questions to ascertain critical skills and behaviors that characterized these broad domains. Finally, both questions and domains were ranked as to their importance and relevance to end-of-life communication in an emergency department setting. Literature review identified five domains of end-of-life care: (1) seek information, (2) assess life values, (3) educate family, (4) extend care in a consistent manner, and (5) respond to family questions and concerns. Within each domain, the expert panel identified subdomains with related behavioral examples that were consistently rated as important to end-of-life care for emergency practitioners. The resulting assessment tool provides a list of skill domains with specific descriptors and clear behavioral examples that can be used as both a teaching and assessment tool. This represents an essential first step that will allow further validation of the assessment tool, ultimately producing a valid and reliable measure of physician skill in emergency medicine end-of-life care.

Intensive Skills Week for Military Medical Students Increases Technical Proficiency, Confidence, and Skills to Minimize Negative Stress

The effects of stress induced cortisol on learning and memory is well documented in the literature.1-3 Memory and learning are enhanced at low levels while high levels are detrimental. Repetitive training in stressful situations enables management of the stress response4 as demonstrated by the high intensity training military members undergo to prepare for tactical situations. Appropriate management of one?s stress response is critical in the medical field, as the negative effects of stress can potentially hinder life-saving procedures and treatments. This also applies to physicians-in-training as they learn and practice triage, emergency medicine, and surgical skills prior to graduation. Rocky Vista University?s Military Medicine Honor?s Track (MMHT) held a week long high-intensity emergency medicine and surgical Intensive Skills Week (ISW), facilitated by military and university physicians, to advance students? skills and maximize training using the Human Worn Partial Surgical Task Simulator (Cut Suit). The short-term goal of the ISW was to overcome negative stress responses to increase confidence, technical and non-technical knowledge, and skill in surgery and emergency medicine in an effort to improve performance as third-year medical students. The long-term goal was to enhance performance and proficiency in residency and future medical practice. The metrics for the short-term goals were the focus of this pilot study. Results show an increase in confidence and decrease in perceived stress as well as statistically significant improvements in technical and non-technical skills and surgical instrumentation knowledge throughout the week. There is a correlative benefit to physician and non-physician military personnel, especially Special Operations Forces (SOF) medical personnel, from developing and implementing similar training programs when live tissue or cadaver models are unavailable or unfeasible.

ECG interpretation skills of South African Emergency Medicine residents

BackgroundThe use and interpretation of electrocardiograms (ECGs) are widely accepted as an essential core skill in Emergency Medicine. It is imperative that emergency physicians are expert in ECG interpretation when they exit their training programme.AimIt is unknown whether South African Emergency Medicine trainees are getting the necessary skills in ECG interpretation during the training programme. Currently there are no clear criteria to assess emergency physicians’ competency in ECG interpretation in South Africa.MethodsA prospective cross-sectional study of Emergency Medicine residents and recently qualified emergency physicians was conducted between August 2008 and February 2009 using a focused questionnaire.ResultsAt the time of the study, there were 55 eligible trainees in South Africa. A total of 55 assessments were distributed; 50 were returned (91%) and 49 were fully completed (89%). In this study, we found the overall average score of ECG interpretation was 46.4% [95% confidence interval (CI) 41.5–51.2%]. The junior group had an overall average of 42.2% (95% CI 36.9–47.5%), whereas the senior group managed 52.5% (95% CI 43.4–61.5%).ConclusionIn this prospective cross-sectional study of Emergency Medicine residents and recently qualified emergency physicians, we found that there was improvement in the interpretation of ECGs with increased seniority. There exists, however, a low level of accuracy for many of the critical ECG diagnoses. The average score of 46.4% obtained in this study is lower than the scores obtained by other international studies from countries where Emergency Medicine is a well-established speciality.

Synergy and sustainability in rural procedural medicine: Views from the coalface

The practice of rural and remote medicine in Australia entails many challenges, including a broad casemix and the remoteness of specialist support. Many rural practitioners employ advanced procedural skills in anaesthetics, surgery, obstetrics and emergency medicine, but the use of these skills has been declining over the last 20 years. This study explored the perceptions of rural general practitioners (GPs) on the current and future situation of procedural medicine. The qualitative results of data from a mixed-method design are reported. Free-response survey comments and semistructured interview transcripts were analysed by a framework analysis for major themes. General practices in rural and remote Queensland. Rural GPs in Rural and Remote Metropolitan Classification 4-7 areas of Queensland. The perceptions of rural GPs on the current and future situation of rural procedural medicine. Major concerns from the survey focused on closure of facilities and downgrading of services, cost and time to keep up skills, increasing litigation issues and changing attitudes of the public. Interviews designed to draw out solutions to help rectify the perceived circumstances highlighted two major themes: 'synergy' between the support from medical teams and community in ensuring 'sustainability' of services. This article presents a model of rural procedural practice where synergy between staff, resources and support networks represents the optimal way to deliver a non-metropolitan procedural service. The findings serve to remind educators and policy-makers that future planning for sustainability of rural procedural services must be broad-based and comprehensive.

Essential tropical emergency medicine skills

Those sandal-clad feet that splash and slap and negotiate the puddles across the 50 or so yards that separate my residence from the suffering and joy and pain and misery...

Basic Emergency Medicine Skills Workshop as the Introduction to the Medical School Clinical Skills Curriculum

Introduction: Most medical school curricula lack training in basic skills needed in a medical emergency. After the September 11th, 2001 terrorist attacks, junior level medical students at our institution volunteered their time in the emergency department[ or at Ground Zero. They quickly realized they had little or no practical training for an emergency situation. Objectives: To correct this curriculum deficit, a five hour basic emergency medicine skills / first responder course for students in their first few weeks of medical school was designed. Methods: The course consists of lectures followed by related skills stations. Lectures include an introduction to the first responder concept, basic airway, breathing, and circulation management, and a rapid, systematic approach to common emergencies. Skills stations teach basic airway management, bag valve mask ventilation, splinting and immobilizing, and moving patients in the field, stressing improvisation. Multiple skills are practiced in a final simulation station using actors with wound moulage and scripted scenarios. Results: This course, instituted at Weill Cornell Medical School in 2002, has become a mainstay of the first year curriculum. Student evaluations have been uniformly superlative. There is strong student sentiment that this is the most practical course of the first year. Conclusion: After six years of experience, we have shown it is possible to present a truncated first responder course as part of the first year curriculum. The course generates tremendous interest and awareness regarding emergency medicine. Future research will examine whether skills taught in this course are retained and can be correctly applied later in medical school.