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Literature has shown cognitive overload which can negatively impact learning and clinical performance in surgery. We investigated learners' cognitive load during simulation-based trauma team training using an objective digital biomarker.A cross-sectional study was carried out in a simulation center where a 3-h simulation-based interprofessional trauma team training program was conducted. A session included three scenarios each followed by a debriefing session. One scenario involved multiple patients. Learners wore a heart rate sensor that detects interbeat intervals in real-time. Low-frequency/high-frequency (LF/HF) ratio was used as a validated proxy for cognitive load. Learners' LF/HF ratio was tracked through different phases of simulation.Ten subjects participated in 12 simulations. LF/HF ratios during scenario versus debriefing were compared for each simulation. These were 3.75 versus 2.40, P 0.001 for scenario 1; 4.18 versus 2.77, P 0.001 for scenario 2; and 4.79 versus 2.68, P 0.001 for scenario 3. Compared to single-patient scenarios, multiple-patient scenarios posed a higher cognitive load, with LF/HF ratios of 3.88 and 4.79, P 0.001, respectively.LF/HF ratio, a proxy for cognitive load, was increased during all three scenarios compared to debriefings and reached the highest levels in a multiple-patient scenario. Using heart rate variability as an objective marker of cognitive load is feasible and this metric is able to detect cognitive load fluctuations during different simulation phases and varying scenario difficulties.

Introduction Nonaccredited simulation fellowships have multiplied resulting in fellowship differences. Standardization of fellowship content and requirements is needed, especially if accreditation is to be achieved. Simulation fellowship criteria were developed using expert consensus and the Accreditation Council for Graduate Medical Education requirements to frame the supporting pillars for accreditation. Methods Core curricular components, subelements, and requirements for graduation were derived from a literature review and existing fellowship curricula. A modified Delphi process was performed to establish fellowship program content and requirements. A priori criteria for inclusion or exclusion were used during 3 iterative rounds. Experts could recommend items for inclusion. Results Fourteen publications and 71 curricula were reviewed with 7 core curriculum components and 44 subelements identified for subsequent expert panel review. All core components were included by consensus: application of teaching and debriefing, business and leadership, curriculum development, educational theory, operational support, research, and assessment and evaluation. Thirty-eight subelements reached consensus. Graduation requirements included a research or scholarly project and a minimum number of debriefing activities, evaluation activities, original simulation curricula, skill-based teaching activities, scenario-based activities, and interprofessional education activities. The maximum number of clinical hours per week was 16 to 20. Conclusions Using a modified Delphi process, experts reached consensus on core curriculum components, subelements, graduation requirements, and maximum number of clinical hours to establish Accreditation Council for Graduate Medical Education accreditation criteria for a simulation standardization of simulation fellowships for physicians. Further work is needed to define other parameters including program infrastructure and assessment.

Background Long-duration exploration missions (LDEMs), such as voyages to Mars, will present unique medical challenges for astronaut crews, including communication delays and the inability to return to Earth early. Medical events threaten crewmember lives and increase the risk of mission failure. Managing a range of potential medical events will require excellent technical and nontechnical skills (NTSs). We sought to identify medical events with potential for rescue, range them according to the potential impact on crew health and mission success during LDEMs, and develop a list of NTSs to train for management of in-flight medical events. Materials and methods Twenty-eight subject matter experts with specializations in surgery, medicine, trauma, spaceflight operations, NTS training, simulation, human factors, and organizational psychology completed online surveys followed by a 2-d in-person workshop. They identified and rated medical events for survivability, mission impact, and impact of crewmember NTSs on outcomes in space. Results Sudden cardiac arrest, smoke inhalation, toxic exposure, seizure, and penetrating eye injury emerged as events with the highest potential mission impact, greatest potential for survival, and that required excellent NTS for successful management. Key NTS identified to target in training included information exchange, supporting behavior, communication delivery, and team leadership/followership. Conclusions With a planned Mars mission on the horizon, training countermeasures need to be developed in the next 3-5 y. These results may inform policy, selection, medical system design, and training scenarios for astronauts to manage in-flight medical events on LDEMs. Findings may extend to surgical and medical care in any rural and remote location.

Objective Our primary aim was to investigate crew performance during medical emergencies with and without ground-support from a flight surgeon located at mission control. Background There are gaps in knowledge regarding the potential for unanticipated in-flight medical events to affect crew health and capacity, and potentially compromise mission success. Additionally, ground support may be impaired or periodically absent during long duration missions. Method We reviewed video recordings of 16 three-person flight crews each managing four unique medical events in a fully immersive spacecraft simulator. Crews were randomized to two conditions: with and without telemedical flight surgeon (FS) support. We assessed differences in technical performance, behavioral skills, and cognitive load between groups. Results Crews with FS support performed better clinically, were rated higher on technical skills, and completed more clinical tasks from the medical checklists than crews without FS support. Crews with FS support also had better behavioral/non-technical skills (information exchange) and reported significantly lower cognitive demand during the medical event scenarios on the NASA-TLX scale, particularly in mental demand and temporal demand. There was no significant difference between groups in time to treat or in objective measures of cognitive demand derived from heart rate variability and electroencephalography. Conclusion Medical checklists are necessary but not sufficient to support high levels of autonomous crew performance in the absence of real-time flight surgeon support Application Potential applications of this research include developing ground-based and in-flight training countermeasures; informing policy regarding autonomous spaceflight, and design of autonomous clinical decision support systems.

Introduction Nontechnical skills (NTS) in medicine are the "cognitive, social, and personal resource skills that complement technical skills contributing to safe and efficient care." We aimed to (1) evaluate the validity and reliability of a 12-element United Kingdom emergency medicine (EM) NTS assessment tool in the context of United States (US) EM practice and (2) identify behaviors unique to US clinical practice. Methods This was a mixed methods study conducted in 2 phases, following Kane's validity framework. The intended use of the NTS tool is to provide formative assessment of US EM physicians (EPs) from a video of simulated clinical encounters. In phase I, a focus group assessed the appropriateness of each aspect of the tool in the context of US EM practice by reviewing and identifying the NTS of an EP in a simulated clinical scenario. In phase II, EPs (N = 208) attending a national EM conference evaluated an EP's behaviors in 1 of 2 video simulations. Reliability in the form of internal consistency was calculated using Cronbach α. All participants suggested exemplar behaviors for the 12 elements in the context of their own clinical practice and generated new assessment elements. Results Internal consistency was acceptable (α > 0.7) for all categories, except teamwork and cooperation. Participants proposed 4 novel behavioral elements and suggested US exemplar behaviors for all 12 original elements. Conclusions This tool can be used to assess US EP's NTS for the purpose of formative assessment. Refinement of exemplar behaviors and inclusion of novel US-specific elements may optimize usability.

Emergency medicine is a complex and challenging specialty. During the course of an emergency medicine training program, residents must achieve competence in a number of domains including technical skills, teamwork, communication, medical knowledge, and multi-tasking. Medical simulation has emerged as a safe, popular, exciting, effective, and valuable educational tool that is particularly well-suited to the training needs of emergency medicine residents (McLaughlin et al., Acad Emerg Med 15(11):1117–1129, 2008; McLaughlin et al., Simulation in emergency medicine. In: Levine et al., editors. The comprehensive textbook of healthcare simulation SE – 20. New York: Springer, 315–328, 2013). This chapter reviews the role that simulation can play in emergency medicine training, highlights some innovative programs and curricula, and describes some common challenges and solutions for implementing a simulation program.

The practice of ultrasound-guided regional anesthesia (UGRA) by emergency medicine physicians in the emergency department (ED) is increasing. The need for effective alternatives to opioid analgesia in the acute care setting likely exceeds the current capacity of UGRA-trained anesthesia teams. In this daring discourse, we outline several matters of relevance to be considered as protocols are put into place to facilitate the practice of UGRA by emergency medicine physicians in the ED. There are opportunities for collaboration between anesthesiology and emergency medicine societies in guideline development as well as educational resources. The sustained interest in UGRA shown by many emergency medicine physicians should be viewed open-mindedly by anesthesiologists. Failure to collaborate on local and national scales could lead to delays in the development and implementation of patient-centered, safe procedural care, and limit patient access to the benefits of regional anesthesia.

Study Objective To examine whether a robotic surgical platform can complement the fine motor skills of the nondominant hand, compensating for the innate difference in dexterity between surgeon's hands, thereby conferring virtual ambidexterity. Design Crossover intervention study (Canadian Task Force classification II-1). Setting Centers for medical simulation in 2 tertiary care hospitals of Harvard Medical School. Participants Three groups of subjects were included: (1) surgical novices (medical graduates with no robotic/laparoscopic experience); (2) surgeons in training (postgraduate year 3–4 residents and fellows with intermediate robotic and laparoscopic experience); and (3) advanced surgeons (attending surgeons with extensive robotic and laparoscopic experience). Interventions Each study group completed 3 dry laboratory exercises based on exercises included in the Fundamentals of Laparoscopic Surgery (FLS) curriculum. Each exercise was completed 4 times: using the dominant and nondominant hands, on a standard laparoscopic FLS box trainer, and in a robotic dry laboratory setup. Participants were randomized to the handedness and setting order in which they tackled the tasks. Measurements and Main Results Performance was primarily measured as time to completion, with adjustments based on errors. Means of performance for the dominant versus nondominant hand for each task were calculated and compared using repeated-measures analysis of variance. A total of 36 subjects were enrolled (12 per group). In the laparoscopic setting, the mean overall time to completion of all 3 tasks with the dominant hand differed significantly from that with the nondominant hand (439.4 seconds vs 568.4 seconds; p = .0008). The between-hand performance difference was nullified with the robotic system (374.4 seconds vs 399.7 seconds; p = .48). The evaluation of performance for each individual task also revealed a statistically significant disparate performance between hands for all 3 tasks when the laparoscopic approach was used (p = .003, .02, and .01, respectively); however, no between-hand difference was observed when the tasks were performed robotically. On analysis across the 3 surgeon experience groups, the performance advantage of robotic technology remained significant for the surgical novice and intermediate-level experience groups. Conclusion Robot-assisted laparoscopy may eliminate the operative handedness observed in conventional laparoscopy, allowing for virtual ambidexterity. This ergonomic advantage is particularly evident in surgical trainees. Virtual ambidexterity may represent an additional aspect of surgical robotics that facilitates mastery of minimally invasive skills.

Recent studies have focused on surgeons' nontechnical skills in the operating room (OR), especially leadership. In an attempt to identify trainee preferences, we explored junior residents' opinions about the OR leadership style of teaching faculty.Overall, 20 interns and 20 mid-level residents completed a previously validated survey on the style of leadership they encountered, the style they preferred to receive, and the style they personally employed in the OR. In all, 4 styles were explored; authoritative: leader makes decisions and communicates them firmly; explanatory: leader makes decisions promptly, but explains them fully; consultative: leader consults with trainees when important decisions are made, and delegative: leader puts the problem before the group and makes decisions by majority opinion. Comparisons were completed using chi-square analysis.Junior resident preference for leadership style of attending surgeons in the OR differed from what they encountered. Overall, 62% of residents encountered an authoritative leadership style; however, only 9% preferred this (p0.001). Instead, residents preferred explanatory (53%) or consultative styles (41%). Preferences differed by postgraduate year. Although 40% of interns preferred a consultative style, 50% of mid-level residents preferred explanatory leadership.Junior resident preference of leadership style in the OR differs from what they actually encounter. This has the potential to create unwanted tension and may erode team performance. Awareness of this difference provides an opportunity for an educational intervention directed at both attendings and trainees.

SummaryObjective: To understand emergency department (ED) physicians’ use of electronic documentation in order to identify usability and workflow considerations for the design of future ED information system (EDIS) physician documentation modules.Methods: We invited emergency medicine resident physicians to participate in a mixed methods study using task analysis and qualitative interviews. Participants completed a simulated, standardized patient encounter in a medical simulation center while documenting in the test environment of a currently used EDIS. We recorded the time on task, type and sequence of tasks performed by the participants (including tasks performed in parallel). We then conducted semi-structured interviews with each participant. We analyzed these qualitative data using the constant comparative method to generate themes.Results: Eight resident physicians participated. The simulation session averaged 17 minutes and participants spent 11 minutes on average on tasks that included electronic documentation. Participants performed tasks in parallel, such as history taking and electronic documentation. Five of the 8 participants performed a similar workflow sequence during the first part of the session while the remaining three used different workflows. Three themes characterize electronic documentation: (1) physicians report that location and timing of documentation varies based on patient acuity and workload, (2) physicians report a need for features that support improved efficiency; and (3) physicians like viewing available patient data but struggle with integration of the EDIS with other information sources.Conclusion: We confirmed that physicians spend much of their time on documentation (65%) during an ED patient visit. Further, we found that resident physicians did not all use the same work-flow and approach even when presented with an identical standardized patient scenario. Future EHR design should consider these varied workflows while trying to optimize efficiency, such as improving integration of clinical data. These findings should be tested quantitatively in a larger, representative study.Citation: Neri PM, Redden L, Poole S, Pozner CN, Horsky J, Raja AS, Poon E, Schiff G, Landman A. Emergency medicine resident physicians’ perceptions of electronic documentation and workflow – a mixed methods study. Appl Clin Inf 2015; 6: 27–41http://dx.doi.org/10.4338/ACI-2014-08-RA-0065

While optical and video laryngoscopy have been studied in the emergency department, the operating room, and the routine prehospital setting, their efficacy in the tactical environment--in which operator safety is as important as intubation success--has not been evaluated. This study compared direct laryngoscopes to optical (AirTraq) and video (King Vision) laryngoscopes in a simulated tactical setting.This prospective institutional review board-approved simulation study evaluated each of the laryngoscopes in the hands of seven experienced tactical paramedics. After a one-hour training session, each tactical paramedic used each of the laryngoscopes, in a random order, on each of four different airway manikins. A tactical environment was simulated using auditory and visual immersion, and the intubations occurred on the ground with the paramedics in full tactical gear. Outcomes included time to successful ventilation, first-pass success rate, Cormack-Lehane grade, and intubator head height during the intubation. Statistical analysis included chi-squared and Wilcoxon rank sum tests, and multivariate logistic regression was performed to determine contributing factors to outcomes with significant variation.A total of 84 intubations were performed by seven tactical paramedics. While there were no significant differences in time to successful ventilation or first-pass success rate, the optical and video laryngoscopes had significantly better Cormack-Lehane grades, defined as grade I or II (100% for both compared to 85.7%), while direct laryngoscopy resulted in significantly less maximum vertical exposure of the intubator (51.82 cm compared to AirTraq's 56.64 cm and King Vision's 56.13 cm).Video and optical laryngoscopes can be used successfully by experienced tactical paramedics in a simulated tactical setting. The King Vision and AirTraq resulted in improved Cormack-Lehane glottic views but similar times to ventilation and first-pass success compared to direct laryngoscopy. Intubator head height was lower with direct laryngoscopy. Clarifying the role of optical and video laryngoscopes in a tactical environment, especially in the hands of less experienced intubators, requires further research.

Introduction At Brigham and Women's Hospital, we identified the need for a comprehensive training program designed to prepare frontline staff to safely manage a patient with Ebola viral disease (EVD). The primary goal of this program was to ensure the safety of staff, patients, and the general public by training staff in the correct use of personal protective equipment (PPE) before, during, and after care of patients with EVD. Methods We delivered a 4-hour experiential training program to frontline health care professionals who would be expected to care for a patient with EVD. The program occurred in a simulation center with multiple flexible spaces and consisted of demonstration, multiple skills practice sessions, and a patient simulation case. We analyzed completed pre- and posttraining questionnaires. The questionnaire assessed their subjective level of confidence in three key areas: donning and doffing PPE, performing clinical skills while wearing PPE, and management of a contamination breach. Results This program was effectively deployed in the STRATUS Center for Medical Simulation over a 4-month period, with 220 health care professionals participating in the training and 195 participants completing the pre-/posttraining questionnaires. Our intervention significantly increased the confidence of participants on each primary objective (p = .001 for all three stations). Discussion This interprofessional simulation-based program has been shown to be a well-received method of training clinicians to manage patients collaboratively during an EVD outbreak. Our intent is that the skills taught in this training program would also be transferable to management of other infectious diseases in the clinical setting.

Article-at-a-Glance Background A study was conducted at a tertiary care academic medical center to assess a simulation-based, single-station Objective Structured Clinical Examination (OSCE) designed to evaluate intern trainees' familiarity with and adherence to behaviors associated with Joint Commission National Patient Safety Goals and The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™. Method Subjects were interns, from all disciplines, completing basic skills training during intern orientation. The OSCE scenario was designed to assess 13 behaviors associated with four National Patient Safety Goals (1, 2, 3, and 7) from 2009 and 2010 and the Universal Protocol. Sessions were digitally recorded and independently reviewed by two observers, who scored behaviors using a standardized score sheet. Behaviors were assigned point values and tabulated for all trainees. Kappa coefficient was calculated to assess interrater reliability. Results One-hundred eleven (74.5%) of 149 interns completed the station. The average time to completion was 6.9minutes (standard deviation [SD] 1.8; range, 3.5–12.6). Interns scored an average of 9.5 points (SD, 4.7; range, 2–20; mode, 8) of 26. The interrater reliability for the two reviewers was 0.9. Interns most frequently requested chlorhexidine to sterilize the patient's skin (98.2% of interns demonstrated); identifying an unlabeled medication vial as inappropriate for use was the most frequently missed item (8.1% of interns demonstrated). Conclusions Behaviors related to tenets of patient safety and quality care can be assessed using a simple to design and execute OSCE. Using simulation to test behaviors associated with the National Patient Safety Goals may be a desirable adjunct to traditional simple knowledge-based tests.

The situational leadership model suggests that an effective leader adapts leadership style depending on the followers' level of competency.We assessed the applicability and reliability of the situational leadership model when observing residents in simulated hospital floor-based scenarios.Resident teams engaged in clinical simulated scenarios. Video recordings were divided into clips based on Emergency Severity Index v4 acuity scores. Situational leadership styles were identified in clips by two physicians. Interrater reliability was determined through descriptive statistical data analysis.There were 114 participants recorded in 20 sessions, and 109 clips were reviewed and scored. There was a high level of interrater reliability (weighted kappa r = .81) supporting situational leadership model's applicability to medical teams. A suggestive correlation was found between frequency of changes in leadership style and the ability to effectively lead a medical team.The situational leadership model represents a unique tool to assess medical leadership performance in the context of acuity changes.

Health care simulation includes a variety of educational techniques used to complement actual patient experiences with realistic yet artificial exercises. This field is rapidly growing and is widely used in emergency medicine (EM) graduate medical education (GME) programs. We describe the state of simulation in EM resident education, including its role in learning and assessment. The use of medical simulation in GME is increasing for a number of reasons, including the limitations of the 80-hour resident work week, patient dissatisfaction with being "practiced on," a greater emphasis on patient safety, and the importance of early acquisition of complex clinical skills. Simulation-based assessment (SBA) is advancing to the point where it can revolutionize the way clinical competence is assessed in residency training programs. This article also discusses the design of simulation centers and the resources available for developing simulation programs in graduate EM education. The level of interest in these resources is evident by the numerous national EM organizations with internal working groups focusing on simulation. In the future, the health care system will likely follow the example of the airline industry, nuclear power plants, and the military, making rigorous simulation-based training and evaluation a routine part of education and practice.

Background Overdoses of calcium channel blocker agents result in hyperglycemia, primarily due to the blockade of pancreatic L-type calcium channels and insulin resistance on the cellular level. The clinical significance of the hyperglycemia in this setting has not previously been described. Methods This study is a retrospective review of all adult (age, >or=15 yrs) patients with a discharge diagnosis of acute verapamil or diltiazem overdose at five university-affiliated teaching hospitals. The severity of overdose was assessed by determining whether a patient met the composite end points of in-hospital mortality, the necessity for a temporary pacemaker, or the need for vasopressors. We compared the initial and peak serum glucose concentrations with hemodynamic variables between patients who did and did not meet the composite end points. Results A total of 40 patients met inclusion criteria, with verapamil and diltiazem accounting for 27 of 40 (67.5%) and 13 of 40 (32.5%) of the ingestions, respectively. For those patients who did and did not meet the composite end points, the median initial serum glucose concentrations were 188 (interquartile range, 143.5-270.5) mg/dL and 129 (98.5-156.5) mg/dL, respectively (p = .0058). The median peak serum glucose concentrations for these two groups were 364 (267.5-408.5) mg/dL and 145 (107.5-160.5) mg/dL, respectively (p = .0001). The median increase in blood glucose was 71.2% for those who met composite end points vs. 0% for those who did not meet composite end points (p = .0067). Neither the change in the median heart rate nor the change in systolic blood pressure was significantly different in any group. Conclusion Serum glucose concentrations correlate directly with the severity of the calcium channel blocker intoxication. The percentage increase of the peak glucose concentration is a better predictor of severity of illness than hemodynamic derangements. If validated prospectively, serum glucose concentration alone might be an indicator to begin hyperinsulinemia-euglycemia therapy.

The most effective treatment for cardiac arrest is the administration of high-quality chest compressions and early defibrillation; once spontaneous circulation is restored, post–cardiac arrest care is essential to support full return of neurologic function. This review summarizes the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of cardiac arrest and resuscitation. Figures show the foundations of cardiac resuscitation, ventricular arrhythmias, coronary perfusion pressure as a function of time, an algorithm for initial treatment of cardiac arrest, sample capnographs, and the electrocardiographic appearance of varying degrees of hyperkalemia. Tables include components of suboptimal cardiac resuscitation and corrective actions, recommended doses of medications commonly used in cardiac resuscitation, causes of pulseless electrical activity/asystolic arrest to consider, immediate post–return of spontaneous circulation checklist, and resuscitation goals during post–cardiac arrest care. This review contains 6 highly rendered figures, 5 tables, and 142 references.

Background The Consortium of American College of Surgeons Accredited Education Institutes (ACS-AEIs) was created to promote patient safety through the use of simulation, develop innovative education and training, advance technologies, identify best practices, and encourage research and collaboration. Methods During the seventh annual meeting of the consortium, leaders from across the consortium who have developed institution-wide simulation centers were invited to participate in a panel to discuss their experiences and the lessons learned. Conclusion These discussions resulted in definition of 5 key areas that need to be addressed effectively to support efforts of the ACS-AEIs.

Cocaine use continues to be prevalent among all races and socioeconomic groups in the United States. Patients presenting to emergency departments after cocaine ingestion frequently present with a chief complaint of chest pain. Although acute myocardial infarction is perhaps the most concerning diagnosis in this setting, there are many other potential causes of chest pain after cocaine ingestion. This article reviews the pharmacology of cocaine, as well as the etiologies and treatment of cocaine-associated chest pain, with an emphasis on this drug's range of cardiovascular effects.

Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events.Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists.A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used.In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.).

With the many advances in rapid reperfusion therapy for management of acute ST segment elevation myocardial infarction (STEMI), there is a need to revisit the current plan for prehospital triage (point of entry). Until recently in Boston, and nationwide, there has been a policy that patients with suspected acute MI were brought to the nearest hospital. Then, if ST segment elevation was present, patients were treated with either thrombolytic therapy or primary percutaneous coronary intervention (PCI). Recent data, however, have shown that with advances in interventional devices, techniques and institutional experience, primary PCI is associated with improved outcomes compared with thrombolytic therapy for all patients with STEMI when provided at expert centers with high institutional volumes, with experienced interventional cardiologists as the operators, and with relatively short time to treatment. We describe the rationale for and the implementation of the Boston EMS STEMI Triage Plan and Treatment Registry. Many of the issues that prompted the implementation of the Boston STEMI plan are relevant to all EMS systems. Among these issues are the accuracy of prehospital identification of STEMI patients, the availability of mechanical reperfusion therapy, the appropriate triage of patients with complicated myocardial infarction or shock, as well as the local consensus regarding strength of the evidence favoring mechanical reperfusion. This article describes the history of the Boston EMS STEMI Triage Plan and Treatment Registry and suggests the need for other EMS systems to develop a systematic approach to patients with STEMI.

Objective Dyspnea is a common complaint of patients treated by emergency medical services (EMS). Few studies have examined the ability of paramedics to distinguish between etiologies of dyspnea. The authors evaluated the degree of agreement related to cardiac versus noncardiac sources of dyspnea between field and emergency department (ED) assessment of patients transported at the advanced life support level. Methods This was a retrospective, cohort study of consecutive patients aged ≥35 years transported by paramedics with dyspnea. The authors compared the concordance between the EMS and ED diagnoses. They also investigated whether patients whose assessments were discordant had worse outcomes. Results Paramedics correctly assessed the cause of dyspnea in 172 of 222 (77%) patients (kappa = 0.60; 95% confidence interval [CI] = 0.51, 0.69). Among single-source (i.e., cardiac or noncardiac) dyspnea patients, prehospital providers correctly assessed 70 of 84 (83%) noncardiac causes and 98 of 114 (86%) cardiac causes (kappa = 0.69; 95% CI = 0.59, 0.79). When the ED diagnosis included both cardiac and noncardiac etiologies, paramedics treated seven of 24 (29%) patients as noncardiac, 13 of 24 (54%) as cardiac, and four of 24 (17%) as combined-source dyspnea. The authors did not observe any statistically significant differences in in-hospital mortality, intubation frequency, or hospital length of stay in patients whose prehospital dyspnea diagnosis was discordant. Conclusion The authors conclude that in this EMS system, field assessment of dyspnea by paramedics is in agreement with that arrived at in the ED in a high proportion of patients with dyspnea from a single source. However, field assessment of dyspnea from multiple etiologies is less concordant.

Objective Patient safety is critical for epilepsy monitoring units (EMUs). Effective training is important for educating all personnel, including residents and nurses who frequently cover these units. We performed a needs assessment and developed a simulation-based team training curriculum employing actual EMU sentinel events to train neurology resident–nurse interprofessional teams to maximize effective responses to high-acuity events. Methods A mixed-methods design was used. This included the development of a safe-practice checklist to assess team response to acute events in the EMU using expert review with consensus (a modified Delphi process). All nineteen incoming first-year neurology residents and 2 nurses completed a questionnaire assessing baseline knowledge and attitudes regarding seizure management prior to and following a team training program employing simulation and postscenario debriefing. Four resident–nurse teams were recorded while participating in two simulated scenarios. Employing retrospective video review, four trained raters used the newly developed safe-practice checklist to assess team performance. We calculated the interobserver reliability of the checklist for consistency among the raters. We attempted to ascertain whether the training led to improvement in performance in the actual EMU by comparing 10 videos of resident–nurse team responses to seizures 4–8 months into the academic year preceding the curricular training to 10 that included those who received the training within 4–8 months of the captured video. Results Knowledge in seizure management was significantly improved following the program, but confidence in seizure management was not. Interrater agreement was moderate to high for consistency of raters for the majority of individual checklist items. We were unable to demonstrate that the training led to sustainable improvement in performance in the actual EMU by the method we used. Conclusions A simulated team training curriculum using a safe-practice checklist to improve the management of acute events in an EMU may be an effective method of training neurology residents. However, translating the results into sustainable benefits and confidence in management in the EMU requires further study.

Study Objective To evaluate risk of leakage and tissue dissemination associated with various contained tissue extraction (CTE) techniques. Design In vitro study (Canadian Task Force classification: II-1). Setting Academic hospital simulation laboratory. Intervention Beef tongue specimens weighing 400 to 500 g were stained using 5 mL indigo carmine dye and morcellated under laparoscopic guidance within a plastic box trainer. CTE was performed via 3 different techniques: a stitch-sealed rip-stop nylon bag and multi-port approach; a one-piece clear plastic 50 × 50-cm isolation bag and multi-port approach; or a 1-piece clear plastic 50 × 50-cm isolation bag and single-site approach. Four trials of each CTE method were performed and compared with an open morcellation control. All bags were insufflated to within 10 to 25 mmHg pressure with a standard CO 2 insufflator. Visual evidence of spilled tissue or dye was recorded, and fluid washings of the box trainer were sent for cytologic analysis. Measurements and Main Results Blue dye spill was noted in only 1 of 12 CTE trials. Spillage was visualized from a seam in 1 of the 4 stitch–sealed rip-stop nylon bags before morcellation of the specimen. The only trial in which gross tissue chips were visualized in the box trainer after morcellation was the open morcellation control. However, cytologic examination revealed muscle cells in the open morcellation washings and in the washings from the trial with dye spill. Muscle cells were not observed at cytologly in any of the other samples. Conclusion CTE did not result in any leakage or tissue dissemination with use of the single-site or multi-port approach when using a 1-piece clear plastic 50 × 50-cm isolation bag. Further studies are needed to corroborate these findings in an in vivo context and to evaluate use of alternate bag options for specimen containment.

Usability testing is increasingly being recognized as a way to increase the usability and safety of health information technology (HIT). Medical simulation centers can serve as testing environments for HIT usability studies. We integrated the quality assurance version of our emergency department (ED) electronic health record (EHR) into our medical simulation center and piloted a clinical care scenario in which emergency medicine resident physicians evaluated a simulated ED patient and documented electronically using the ED EHR. Meticulous planning and close collaboration with expert simulation staff was important for designing test scenarios, pilot testing, and running the sessions. Similarly, working with information systems teams was important for integration of the EHR. Electronic tools are needed to facilitate entry of fictitious clinical results while the simulation scenario is unfolding. EHRs can be successfully integrated into existing simulation centers, which may provide realistic environments for usability testing, training, and evaluation of human–computer interactions.

Over 1,000 people suffer sudden cardiac death every day in the United States. About half occur in the hospital, the remainder occurring in the home, outpatient medical environments, or public spaces. The ultimate goal of cardiac resuscitation is survival with full neurologic recovery. Interventions that have the greatest potential to provide this outcome are often those interventions that can be performed by trained laypersons. Delay in the initiation of compressions in a cardiac arrest is one of the leading predictors of mortality. This chapter deliberately opens with a discussion of one of the most vital, yet relatively under-appreciated aspects of cardiac resuscitation—teamwork. Following an overview of cardiac arrest, the chapter covers epidemiology and recognition of cardiac arrest, then activation of the emergency response system. Chest compressions, defibrillation and airway management are discussed, then end-tidal CO2, vascular access, rhythm analysis during cardiac arrest, and drugs used during cardiac resuscitation. The chapter concludes with a look at postresuscitation care, special considerations in cardiac arrest, and future directions. Figures include the foundations of cardiac resuscitation, a management algorithm for the initial treatment of cardiac arrest, coronary perfusion pressure as a function of time, an impedance threshold device incorporated into a bag-valve mask, a colorimetric CO2 detector, four basic phases of a capnogram, sample capnographs, a battery-powered intraosseous drill, electrocardiogram readouts of ventricular arrhythmias, a sonogram of large pericardial effusion, and electrocardiographic appearance of varying degrees of hyperkalemia. Tables summarize recommendations from the American Heart Association, the components of optimal and suboptimal chest compressions, and underlying causes of nonshockable rhythms and their management. This chapter contains 11 highly rendered figures, 3 tables, 138 references, 5 MCQs.

Chest compressions have saved the lives of countless patients in cardiac arrest as they generate a small but critical amount of blood flow to the heart and brain. This is achieved by direct cardiac massage as well as a thoracic pump mechanism. In order to optimize blood flow excellent chest compression technique is critical. Thus, the quality of the delivered chest compressions is a pivotal determinant of successful resuscitation. If a patient is found unresponsive without a definite pulse or normal breathing then the responder should assume that this patient is in cardiac arrest, activate the emergency response system and immediately start chest compressions. Contra-indications to starting chest compressions include a valid Do Not Attempt Resuscitation Order. Optimal technique for adult chest compressions includes positioning the patient supine, and pushing hard and fast over the center of the chest with the outstretched arms perpendicular to the patient's chest. The rate should be at least 100 compressions per minute and any interruptions should be minimized to achieve a minimum of 60 actually delivered compressions per minute. Aggressive rotation of compressors prevents decline of chest compression quality due to fatigue. Chest compressions are terminated following return of spontaneous circulation. Unconscious patients with normal breathing are placed in the recovery position. If there is no return of spontaneous circulation, then the decision to terminate chest compressions is based on the clinical judgment that the patient's cardiac arrest is unresponsive to treatment. Finally, it is important that family and patients' loved ones who witness chest compressions be treated with consideration and sensitivity.

Current airway management for most first-responder basic emergency medical technicians (EMT-Bs) does not include the use of blind-advanced-airway devices.To compare the speed, success rates, and skill retention with which EMT-Bs providers can place three blind-advanced-airway devices.Prospective study of 43 EMT-Bs trained in the use of the Esophageal-Tracheal-Combitube(®) (ETC), King LT(®) (KLT), and Laryngeal Mask Airway(™) (LMA). The time it took each participant to place each device correctly and ventilate a human patient simulator was assessed. Primary outcome measures were the success rate of proper insertion for each device and time interval from initiation of mouth insertion to initiation of chest rise. To assess skill retention, at 3 months the providers were reassessed under exact conditions.At Day 1, time required to place an ETC, LMA, and KLT were 32.7 ± 12.3, 19.2 ± 6.2, and 20.1 ± 6.6 s, respectively. Using paired t-tests, LMA and KLT were faster than ETC, p0.0001. At 3 months, pair-wise comparisons showed the ETC took longer to place than the KLT and LMA, p0.0001; and the LMA took longer to place than the KLT, p = 0.0034 (36.4 ± 13.1 ETC, 24.8 ± 12.4 LMA, 19.0 ± 6.9 KLT). There was no statistical difference of failures in placing any device.Comparison of three rescue airway devices placed by EMT-Bs providers showed that it takes significantly longer to place an ETC compared to an LMA and KLT both on Day 1 and 3 months later. Three-month retention studies revealed that it took significantly longer to place an LMA compared to the KLT.

High-quality chest compressions (CCs) are an important component of successful resuscitation. Suboptimal in-hospital CC are commonly reported. Skill degradation and fatigue have been implicated. We assessed the effect of a handheld feedback device on the measured and perceived quality of CC and rescuer physiologic response.This is a nonblinded randomized controlled study of nurses at an academic medical center. Participants performed CC on a mannequin either with or without a feedback device. Compression rate (CR) and compression depth (CD), heart rate, and oxygen saturation were documented. Perceived quality of CC, fatigue, and ease of use of the device were obtained.Twelve nurses were in the feedback group (FG) and 13 were controls. Mean CD was significantly higher in the FG (1.99 ± 0.37 in vs 1.52 ± 0.36 in; P = .005) and mean CR significantly lower in the FG (127 ± 13.8 per min vs 101 ± 9.7 per min; P ≤ .0001). Using a CD of more than 1.5 in and a CR of 90 to 100 as a composite measure of high-quality CC, the FG performed significantly better (81.4% ± 22.0% vs 10.4% ± 21.9%; P.0001). Perceived CD, CR, and fatigue did not differ between groups; however, participants overestimated depth and underestimated rate. The FG rated the design as user-friendly (85% + 26%) helpful in maintaining correct CR (83% + 26%).A handheld accelerometer-based audiovisual cardiopulmonary resuscitation (CPR) feedback device significantly improved the quality of CCs provided by experienced hospital nurses in a simulated setting, with no perceived or measured difference in fatigue between the 2 groups. The CPR feedback provides an effective means to monitor and improve CPR performance.

Introduction:Prehospital emergency services are a vital public service, and consumer access to the system is an important factor in their use. The Dominican Republic recently experienced “the epidemiological transition” leading to increased morbidity and mortality secondary to traumatic and cardiac conditions—thus, increasing the need for prompt and adequate delivery of emergency medical care.Methods:A survey was administered to 90 subjects from diverse backgrounds, all living in Santo Domingo. Survey items included questions on emergency medical services (EMS) systems knowledge (i.e., access numbers), confidence in the system, first-aid education and prior experience with the EMS system. Chi-square was used to measure statistical significance for categorical variables and Student's t-test for continuous variables (JMP 2.0 software was used for statistical processing).Results:A total of 90 subjects were surveyed. The average age of respondents was 36 ± 12 years SD. More than one-fifth (22.2%) of respondents did not know the established universal emergency number (9-1-1), and 37.8% responded that they would access a different telephone number in case of a medical emergency.Conclusions:Important deficiencies and access-to-care concerns were interpreted from the results. An adequate understanding of the current state of prehospital care could lead to creation of policies by system administrators to further improve the delivery of emergency medical care. This study will assist system administrators in future design and policy issues.

Emergency medical services (EMS) is an organised system designed to transport sick or injured patients to the hospital. Though EMS system configurations can be quite varied in design depending on locale, we provide an overview of EMS as it has evolved and is currently modelled in the US. We outline the history of EMS in the US, including the major events and legislation that shaped the current models that are in existence. We provide an overview of provider training, system design, system funding, and dispatch issues. The concepts of medical direction for physician surrogates, as well as EMS as it relates to specialty care are also elucidated.

In December 1999, a group of emergency physicians from the United States, Israel, and Ethiopia met for the Second Annual Symposium on Emergency Medicine and to perform an initial evaluation of the prehospital care system in Addis Ababa. The symposium was structured into a workshop on prehospital care and a clinical seminar for emergency medicine providers. This article describes the current prehospital infrastructure in Addis Ababa, Ethiopia. This serves as the basis for more specific needs assessments and training interventions, which are ongoing. The authors present a list of priorities for the development of an emergency medical services (EMS) system for Addis Ababa that was generated in partnership with local government and the World Health Organization. The article contrasts these initial recommendations with those found in the literature on the development of EMS systems in developing nations.

Study objective The potential of infectious disease spread in diseases such as tuberculosis, infectious disease epidemic such as avian flu and the threat of terrorism with agents capable of airborne transmission have focused attention on the need for increased surge capacity for patient isolation. Total negative pressure isolation using portable bioisolation tents may provide a solution. The study assesses the ability of health care workers to perform emergency procedures in this environment. Methods Physician performance in completing predetermined critical actions in 5 emergency care scenarios inside and outside of a bioisolation tent ("setting") was studied in an advanced medical simulation laboratory. By design, no pretraining of subjects about total negative pressure isolation use occurred. Impact of setting on time to completion of predetermined critical actions was the primary outcome measured. Secondary variables studied included impact of study groups, scenarios, and run order (inside or outside of the tent first). Subjective assessments were obtained through questionnaires. Results Four teams of 3 physicians completed 5 emergency patient care scenarios during 2 4-hour sessions. Mean time to completion of critical actions was for tent/no tent 298 seconds/284 seconds (P=.69, one way ANOVA), respectively. Mean time to completion for first versus second performance of a scenario in the crossover design was 338 versus 243 (P=.01). The mean score for self-assessed performance did not differ according to setting. Conclusion The ability of physicians naive to the total negative pressure isolation environment to perform emergency medical critical actions was not significantly degraded by a simulated bioisolation tent patient care environment.

Medical simulation allows trainees to experience realistic patient situations without exposing patients to the risks inherent in trainee learning and is adaptable to situations involving widely varying clinical content. Although medical simulation is becoming more widely used in medical education, it is typically used as a complement to existing educational strategies. Our approach, which involved a complete curriculum redesign to create a fully integrated medical simulation model with an "all at once" implementation, represents a significant departure from conventional graduate medical education models. We applied adult learning principles, medical simulation learning theory, and standardized national curriculum requirements to create an innovative set of simulation-based modules for integration into our emergency medicine residency curriculum. Here we describe the development of our simulation modules using various simulation technologies, their implementation, and our experiences during the first year of integration.