Simulation Lab Training

From the Journal of Emergency Medicine:

Background: Simulation (SIM) allows medical students to manage high-risk/low-frequency cases in an environment without patient risk. However, evidence for the efficacy of SIM-based training remains limited.

Objective: To compare SIM-based training to traditional didactic lecture (LEC) for teaching medical students to assess and manage critically ill patients with myocardial infarction (MI) and anaphylaxis.

Methods: Prospective, randomized, non-blinded crossover study of 28 fourth-year medical students. Students were oriented to the human patient simulator, then randomized to SIM or LEC between August and December 2007. The SIM group learned to manage MI using SIM training and the LEC group learned via PowerPoint lecture. All subjects’ assessment and management skills were then evaluated during a simulation session of MI. During a second instruction session, the students crossed over and were taught anaphylaxis using the opposite modality and similar assessments were conducted. Completion of critical actions for each case were scored, converted to percentages, and analyzed via signed rank test.

Results: Of 28 subjects, 27 performed better when trained with SIM compared with LEC (p < 0.0001). Mean scores were 93% (95% confidence interval [CI] 91–95%) of critical actions completed for SIM and 71% (95% CI 66–76%) for LEC. Absolute increase for simulation was 22% (95% CI 18–26%). For three domains common to MI and anaphylaxis, simulation scores were higher for history (27%, 95% CI 21–38%), physical examination (26%, 95% CI 20–33%), and management (16%, 95% CI 11–21%).

Conclusion: SIM training is superior to didactic lecture for teaching fourth-year medical students to assess and manage simulated critically ill MI and anaphylaxis patients.

Family Presence at Resuscitation

From Kevin MD:

Forty or so minutes had passed since the patient arrived and, as I had explained to the wife in the family room, time was not our friend. We had no other options of treatment to save this patient.

“Please, stop,” the wife said. “Please, just let him go in peace.”

A powerful moment.

Assault of a Paramedic as Augmented Reality

From Gizmodo:

This augmented reality billboard in the Netherlands involuntarily pulls passersby into a scene depicting the brutal beating of a paramedic. As the shock wears off, the billboard delivers a brief message regarding the citizens’ role in prevention/cessation of violence.

Hospitals post wait time for ER service

From the Tennessean:

As the average wait time to be seen in an emergency has grown to nearly an hour, hospitals around the country and Tennessee have stepped up initiatives to reduce wait times.

But TriStar is one of the first in Nashville to actually tell patients the wait times.

TriStar launched a campaign this week to post real-time emergency room wait times using billboards, the Internet, text messaging and iPhones.

Effect of Intensive Physician Oversight on A Prehospital Rapid-Sequence Intubation Program

From Prehospital Emergency Care:

Objective. To examine the effects of adding close concurrent and retrospective physician oversight, consistent with National Association of EMS Physicians (NAEMSP) recommendations, to an existing regional prehospital rapid-sequence intubation (RSI) program. Methods. This study involved a retrospective cohort of patients receiving RSI between January 1, 2004, and July 31, 2008. On January 1, 2007, an updated program including additional concurrent and retrospective physician oversight, increased RSI-specific continuing medical education, and cadaver laboratory training was implemented. Study patients were divided into a preintervention group (group 1) and a postintervention group (group 2) based on date of medical care. Data regarding baseline characteristics, airway management, medication usage, and performance factors were compared between the groups. A retrospective review by two emergency medical services (EMS) physicians assessed whether the RSI was “clearly indicated” based on a predetermined set of criteria. Results. There were 109 RSIs performed in group 1 and 54 in group 2. Absolute increases in the use of both basic life support (BLS) (5%, p = 0.2) and advanced life support (ALS) (41%, p = 0.001) airway techniques were observed. Increases in postintubation administration of midazolam (30%, p = 0.001) and morphine (24%, p = 0.001) and a decrease for vecuronium (–28%, p = 0.001) were observed. There was no statistically significant difference in the intubation success rates (92% vs. 94%) and the frequencies of recognized esophageal endotracheal tube (ETT) placement (5% vs. 6%). The number of unrecognized esophageal ETT placements remained zero. Physician chart review demonstrated an absolute increase in “clearly indicated” RSIs (17%, p = 0.01). Conclusions. Close concurrent and retrospective physician oversight consistent with recommendations from the NAEMSP is associated with improved cognitive skills in paramedics, including appropriate patient selection for RSI. Further research is warranted to validate this model and optimize where resources are best used to enhance patient safety and improve clinical management for this controversial paramedic skill.

New Initiative Designed to Reduce ER Visits

From the Chillicothe Gazette:

The Ohio Department of Job and Family Services has announced the kickoff of a new initiative designed to reduce the number of avoidable emergency room visits in the state.

A kickoff meeting for IMPROVE (Implementing Medicaid Programs for the Reduction of Avoidable Visits to the Emergency Department) is scheduled for this morning in Columbus.

Delayed Prehospital Implementation of the 2005 American Heart Association ECC Guidelines

From Prehospital Emergency Care:

Introduction. In 2005, the American Heart Association (AHA) released guidelines to improve survival rates from out-of-hospital cardiac arrest (OHCA). Objective. To determine if, and when, emergency medical services (EMS) agencies participating in the Resuscitation Outcomes Consortium (ROC) implemented these guidelines.Methods. We contacted 178 EMS agencies and completed structured telephone interviews with 176 agencies. The survey collected data on specific treatment protocols before and after implementation of the 2005 guidelines as well as the date of implementation crossover (the “crossover date”). The crossover date was then linked to a database describing the size, type, and structure of each agency. Descriptive statistics and regression were used to examine patterns in time to crossover. Results. The 2005 guidelines were implemented by 174 agencies (99%). The number of days from guideline release to implementation was as follows: mean 416 (standard deviation 172), median 415 (range 49–750). There was no difference in time to implementation in fire-based agencies (mean 432), nonfire municipal agencies (mean 365), and private agencies (mean 389, p = 0.31). Agencies not providing transport took longer to implement than agencies that transported patients (463 vs. 384 days, p = 0.004). Agencies providing only basic life support (BLS) care took longer to implement than agencies who provided advanced life support (ALS) care (mean 462 vs. 397 days, p = 0.03). Larger agencies (>10 vehicles) were able to implement the guidelines more quickly than smaller agencies (mean 386 vs. 442 days, p = 0.03). On average, it took 8.9 fewer days to implement the guidelines for every 50% increase in EMS-treated runs/year to which an agency responded. Conclusion. ROC EMS agencies required an average of 416 days to implement the 2005 AHA guidelines for OHCA. Small EMS agencies, BLS-only agencies, and nontransport agencies took longer than large agencies, agencies providing ALS care, and transport agencies, respectively, to implement the guidelines. Causes of delays to guideline implementation and effective methods for rapid EMS knowledge translation deserve investigation.