[Show abstract][Hide abstract] ABSTRACT: 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.
Academic Emergency Medicine 12/2012; 19(12):1442-53. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Basic medical procedures have historically been taught at the bedside, without a formal curriculum. The supervision of basic procedures is often provided by the next most senior member of the health care team, who themselves may have very little experience. This approach does not allow for preparatory reading or deliberate practise of the procedure, and trainees often track the number of completed procedures as the only evidence of competency, without documented assessments of quality. Context: The conscious competence model is a learning paradigm for acquiring a new skill that can be applied to teaching medical procedures. There are multiple stages for effectively learning how to competently perform a procedure, which should not be distilled down into bedside demonstration alone. Learners can be guided through these stages to allow progression towards competency to perform a procedure unsupervised. Innovation: We propose a novel approach that divides procedural education into a four-step process that covers knowledge, experience, technical skill development and competency evaluation. The stages of competency outlined here can be tailored, with incremental expectations for any medical procedure and any level of learner. Implications: This educational paradigm alters the current structure of teaching procedures at any level of medical education, with the goals of better comprehension, skill retention and decreased adverse outcomes. Graded objectives based on learner level can be determined by educators for each clinical procedure. This four-step framework for teaching medical procedures will make the adage 'see one, do one, teach one' obsolete.
[Show abstract][Hide abstract] ABSTRACT: OVERVIEW This supplement provides a summary of the teaching points that appear in the ac-companying video, which demonstrates the equipment and techniques used to per-form emergency pericardiocentesis in adults. INDICATIONS Pericardiocentesis is indicated as an emergency procedure in patients with cardiac tamponade. Accumulation of fluid in the pericardial sac can increase the pressure around the heart. The intrapericardial pressure then increases until it equals the right ventricular diastolic pressure and then the left ventricular diastolic pressure, which leads to impaired cardiac filling and decreased cardiac output. 1 The drop in cardiac output resulting from this increased pressure can be severe enough to cause pulseless electrical activity. Because of the distensibility of the pericardial sac, large amounts of fluid can accumulate gradually without hemodynamic effects. How-ever, rapid accumulation of a small amount of fluid may overwhelm the distensibil-ity of the pericardium with a rapid increase in intrapericardial pressure, leading to hemodynamic compromise. 2 The classic presentation of patients with pericardial tamponade includes Beck's triad of jugular venous distention from elevated systemic venous pressure, distant heart sounds, and hypotension. 3 Most patients will have at least one of these signs; all three rarely appear simultaneously, and then only briefly before cardiac arrest. Jugular venous distention can be difficult to assess in obese or hypovolemic patients. Distant heart sounds may signify a pericardial effusion but can also occur in re-sponse to obesity or chronic obstructive pulmonary disease. A pericardial friction rub may or may not be present, regardless of the size of the effusion, 1 but is often pres-ent with an inflammatory effusion. 2 Tachypnea is a common clinical finding in pa-tients with cardiac tamponade, 1 and dyspnea is the most frequently reported symp-tom on presentation, 4 with a sensitivity of about 87 to 88% for cardiac tamponade. 1,5 Other signs of cardiac tamponade include a pulsus paradoxus (a drop in sys-tolic pressure greater than 10 mm Hg during normal inspiration), an electrocar-diogram with a low-voltage QRS or electrical alternans, and Kussmaul's sign, in which there is increased jugular venous distention on inspiration. In most cases, acute pericardial fluid collection is not detected on chest radiography unless more than 200 ml of fluid has accumulated. Enlarged cardiac silhouettes are more likely to be seen in cases of postsurgical or chronic pericardial fluid collections. In such patients, the detection of cardiomegaly on chest radiography has a sensi-tivity of about 89% for cardiac tamponade. 1 The rate of pericardial fluid accumulation has a sizable effect on the rate of clinical decompensation. The pericardial sac normally contains 15 to 30 ml of se-rous fluid. 1 A patient with a rapidly accumulating pericardial effusion may present with severe respiratory distress, agitation, tachycardia, and hypotension, followed by quick progression to obtundation, bradycardia, and pulseless electrical activity. Pericardial tamponade can result from the accumulation of effusion fluids, blood, infectious purulent material, or gas within the pericardial space. Simple pericar-dial effusions with a single collection of serous fluid may be amenable to uncom-plicated pericardiocentesis, but drainage of more complex effusions, such as locu-lated collections of infectious material, may be more difficult. Patients at risk for pericardial tamponade include those with metastatic cancer, a history of mediastinal radiation, end-stage renal disease, recent cardiac surgery, or traumatic injury. Other causes of pericardial tamponade may include pericardi-tis, myocardial infarction, congestive heart failure, collagen vascular disease, and tuberculosis. 1 Pericardial tamponade should be considered as a possible cause of cardiac arrest with pulseless electrical activity. Bedside ultrasonography can be used to detect the presence of pericardial fluid and features of pericardial tamponade. Practitioners without ultrasound expertise should consider consultation with a qualified radiologist or cardiologist for as-sistance in interpreting diagnostic studies, depending on a patient's clinical cir-cumstances. The presence of pericardial fluid and the diastolic collapse of the right atrium or ventricle are diagnostic of pericardial tamponade. 1,2,5,6 Other find-ings that may further support this diagnosis include a dilated inferior vena cava without respiratory variations in size or changes in flow velocities across the tri-cuspid and mitral valves. 1,2,6 In patients with pericardial tamponade, emergency pericardiocentesis to aspi-rate pericardial fluid can restore normal cardiac function and peripheral perfu-sion. It can be a lifesaving procedure.
New England Journal of Medicine 03/2012; 366(12):e17. · 54.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Spontaneous globe subluxation is an uncommon problem that develops acutely and can present with significant patient distress from ocular pain and vision loss. OBJECTIVES: To present an unusual case of recurrent spontaneous globe subluxation and describe several methods emergency physicians can use to reduce a subluxation. CASE REPORT: We describe a patient with recurrent spontaneous globe subluxation who presented to the Emergency Department with acute ocular pain and vision loss. The subluxation was emergently reduced, resolving the pain and restoring normal vision. Various manual reduction techniques are discussed. CONCLUSION: There are a number of manual reduction techniques used for treating spontaneous globe subluxation.
Journal of Emergency Medicine 02/2012; · 1.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this study is to identify (1) the current role of simulation in medical student emergency medicine (EM) education; (2) the challenges to initiating and sustaining simulation-based programs; and (3) educational advances to meet these challenges.
We solicited members of the Clerkship Directors in Emergency Medicine (CDEM) e-mail list to complete a Web-based survey addressing the use of simulation in both EM clerkships and preclinical EM curricula. Survey elements addressed the nature of the undergraduate EM clerkship and utilization of simulation, types of technology, and barriers to increased use in each setting.
CDEM members representing 60 EM programs on the list (80%) responded. Sixty-seven percent of EM clerkships are in the fourth year of medical school only and 45% are required. Fewer than 25% of clerkship core curriculum hours incorporate simulation. The simulation modalities used most frequently were high-fidelity models (79%), task trainers (55%), and low-fidelity models (30%). Respondents identified limited faculty time (88.7%) and clerkship hours (47.2%) as the main barriers to implementing simulation training in EM clerkships. Financial resources, faculty time, and the volume of students were the main barriers to additional simulation in preclinical years.
A focused, stepwise application of simulation to medical student EM curricula can help optimize the ratio of student benefit to faculty time. Limited time in the curriculum can be addressed by replacing existing material with simulation-based modules for those subjects better suited to simulation. Faculty can use hybrid approaches in the preclinical years to combine simulation with classroom settings for either small or large groups to more actively engage learners while minimizing identified barriers.
The western journal of emergency medicine 11/2011; 12(4):455-60.
[Show abstract][Hide abstract] ABSTRACT: This educational resource provides the information and materials for a high-fidelity simulation case suitable for resident physicians in emergency medicine. This case is currently in use at our institution for emergency medicine residents completing required educational time in our Emergency Department Simulation Program. This case has been used for the past four years in our program and has recently been edited and expanded to its existing form. This high-fidelity patient simulation case involves a patient presenting with an unstable atrial tachycardia (Option #1 is atrial flutter; Option #2 is atrial fibrillation). Evaluation in the emergency department demonstrates a narrow-complex tachycardia and low blood pressure. Appropriate treatment with synchronized cardioversion will allow stabilization of the patient. Debriefing materials are provided to illustrate and stimulate discussion of the important concepts for diagnosing and treating patients with atrial tachycardias.
[Show abstract][Hide abstract] ABSTRACT: Previous work shows feasibility for large group high-fidelity simulation with correlation to basic science in the preclinical curriculum.
This project studies whether large group simulation leads to enhanced basic science learning.
This was an educational performance study before and after high-fidelity simulation for first-year medical students. Basic neuroscience concepts were reinforced with simulation, and pretesting and posttesting were analysed along with summative exam results. The number correct was compared on a contingency table using the Mantel-Haenszel chi-squared test and same student correlation was accounted for with a 'Generalized Estimating Equations' model.
The study included 112 students; three were excluded for missing data. Students showed statistically significant improvement on two of the four questions, and a nonsignificant improvement or equivalent performance on two questions. Students were significantly more likely to get all four responses correct on the posttest than on the pretest. Summative testing 11 days later had >80% correct responses for three factual recall questions and 58% correct responses for a single knowledge application question.
Simulation is an effective teaching method for preclinical basic science education. Students demonstrated significant improvements after participating in a live interactive simulation scenario.
Medical Teacher 05/2009; 31(5):e206-10. · 2.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objectives were to assess emergency physician (EP) understanding of the Centers for Medicare and Medicaid Services (CMS) core measures for community-acquired pneumonia (CAP) guidelines and to determine their self-reported effect on antibiotic prescribing patterns.
A convenience sample of EPs from five medical centers in North Carolina was anonymously surveyed via a Web-based instrument. Participants indicated their level of understanding of the CMS CAP guidelines and the effects on their prescribing patterns for antibiotics.
A total of 121 EPs completed the study instrument (81%). All respondents were aware of the CMS CAP guidelines. Of these, 95% (95% confidence interval [CI] = 92% to 98%) correctly understood the time-based guidelines for antibiotic administration, although 24% (95% CI = 17% to 31%) incorrectly identified the onset of this time period. Nearly all physicians (96%; 95% CI = 93% to 99%) reported institutional commitment to meet these core measures, and 84% (95% CI = 78% to 90%) stated that they had a department-based CAP protocol. More than half of the respondents (55%; 95% CI = 47% to 70%) reported prescribing antibiotics to patients they did not believe had pneumonia in an effort to comply with the CMS guidelines, and 42% (95% CI = 34% to 50%) of these stated that they did so more than three times per month. Only 40% (95% CI = 32% to 48%) of respondents indicated a belief that the guidelines improve patient care. Of those, this was believed to occur by increasing pneumonia awareness (60%; 95% CI = 52% to 68%) and improving hospital processes when pneumonia is suspected (86%; 95% CI = 80% to 92%).
Emergency physicians demonstrate awareness of the current CMS CAP guidelines. Most physicians surveyed reported the presence of institutional protocols to increase compliance. More than half of EPs reported that they feel the guidelines led to unnecessary antibiotic usage for patients who are not suspected to have pneumonia. Only 40% of EPs believe that CAP awareness and expedient care resulting from these guidelines has improved overall pneumonia-related patient care. Outcome-based data for non-intensive care unit CAP patients are lacking, and EPs report that they prescribe antibiotics when they may not be necessary to comply with existing guidelines.
Academic Emergency Medicine 02/2009; 16(2):184-7. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Clinical procedures taught in the undergraduate medical curriculum are important for subsequent residency training and clinical practice. Published reports suggest that medical schools may not be adequately teaching procedures. This study identifies procedures considered essential by residents completing internship and by medical school faculty, and determines agreement on their importance for medical student education.
Two hundred and thirty-five physicians (184 new physicians who recently completed internship and 51 medical school teaching faculty) categorized 31 clinical procedures based on the importance for internship. New physicians who had completed internship reported the level of training received in medical school for each procedure.
Survey responses were 76% (faculty) and 70% (new physicians who had completed internship). The faculty majority identified 14 procedures as 'Must Know.' New physicians disagreed on 8 of these and categorized an additional 5 as essential. There was 32% concordance for the 19 procedures identified by either group. New physicians reported 'Limited Hands-On Training' for all 19 procedures but 'Comprehensive Hands-On Training' for only two.
New physicians who have completed internship and medical school faculty do not agree on procedures essential for internship. A core educational list of 19 procedures was identified using the responses from these two groups.
Medical Teacher 01/2009; 31(4):342-7. · 2.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
Academic Emergency Medicine 11/2008; 15(11):1117-29. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Simulation allows educators to develop learner-focused training and outcomes-based assessments. However, the effectiveness and validity of simulation-based training in emergency medicine (EM) requires further investigation. Teaching and testing technical skills require methods and assessment instruments that are somewhat different than those used for cognitive or team skills. Drawing from work published by other medical disciplines as well as educational, behavioral, and human factors research, the authors developed six research themes: measurement of procedural skills; development of performance standards; assessment and validation of training methods, simulator models, and assessment tools; optimization of training methods; transfer of skills learned on simulator models to patients; and prevention of skill decay over time. The article reviews relevant and established educational research methodologies and identifies gaps in our knowledge of how physicians learn procedures. The authors present questions requiring further research that, once answered, will advance understanding of simulation-based procedural training and assessment in EM.
Academic Emergency Medicine 10/2008; 15(11):1079-87. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Developing technical expertise in medical procedures is an integral component of emergency medicine (EM) practice and training. This article is the work of an expert panel composed of members from the Society for Academic Emergency Medicine (SAEM) Interest Group, the SAEM Technology in Medical Education Committee, and opinions derived from the May 2008 Academic Emergency Medicine Consensus Conference, "The Science of Simulation in Healthcare." The writing group reviewed the simulation literature on procedures germane to EM training, virtual reality training, and instructional learning theory as it pertains to skill acquisition and procedural skills decay. The authors discuss the role of simulation in teaching technical expertise, identify training conditions that lead to effective learning, and provide recommendations for future foci of research.
Academic Emergency Medicine 10/2008; 15(11):1046-57. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Bacterial meningitis and viral encephalitis are infectious disease emergencies that can cause significant patient morbidity and mortality. Clinicians use epidemiologic, historical, and physical examination findings to identify patients at risk for these infections, and central nervous system (CNS) imaging and lumbar puncture (LP) may be needed to further evaluate for these diagnoses. The diagnosis of bacterial meningitis can be challenging, as patients often lack some of the characteristic findings of this disease with presentations that overlap with more common disorders seen in the emergency department. This article addresses considerations in clinical evaluation, need for CNS imaging before LP, interpretation of cerebrospinal fluid results, standards for and effects of timely antibiotic administration, and recommendations for specific antimicrobial therapy and corticosteroids.
Infectious Disease Clinics of North America 04/2008; 22(1):33-52, v-vi. · 2.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Infectious diseases of the CNS lead to overwhelming inflammatory processes within the brain and spinal cord that contribute substantially to patient morbidity and mortality. Pharmacological strategies to modulate inflammation have been investigated, although the resulting guidelines have sometimes been contradictory. Steroids have been proposed as adjunctive treatments for bacterial meningitis, tuberculous meningitis and herpes simplex virus encephalitis. Well-designed randomized controlled trials have established dexamethasone as an adjunctive therapy for adult patients receiving antibiotics for bacterial meningitis, and physicians prescribing the initial antibiotics need to be aware of current guidelines. Morbidity and mortality in patients with tuberculous meningitis exceeds 50%. Steroid treatments reduce mortality through an as yet unknown mechanism, although their effects on morbidity are less clear. Herpes simplex virus encephalitis is also associated with considerable morbidity and mortality. Despite a lack of randomized trials, there is some evidence that steroids used alongside antiviral therapy might be beneficial in this condition. As we discuss in this Review, systemic steroid treatment is an important aspect of treatment regimens for CNS infectious diseases, and the recent literature provides guidelines for the use of steroids in combination with appropriate antimicrobial therapy.
Nature Clinical Practice Neurology 03/2008; 4(2):97-104. · 7.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Spinal cord and brain injuries lead to complex cellular and molecular interactions within the central nervous system in an attempt to repair the initial tissue damage. Many studies have illustrated the importance of the glial cell response to injury, and the influences of inflammation and wound healing processes on the overall morbidity and permanent disability that result. The abortive attempts of neuronal regeneration after spinal cord injury are influenced by inflammatory cell activation, reactive astrogliosis and the production of both growth promoting and inhibitory extracellular molecules. Despite the historical perspective that the glial scar was a mechanical barrier to regeneration, inhibitory molecules in the forming scar and methods to overcome them have suggested molecular modification strategies to allow neuronal growth and functional regeneration. Unlike myelin associated inhibitory molecules, which remain at largely static levels before and after central nervous system trauma, inhibitory extracellular matrix molecules are dramatically upregulated during the inflammatory stages after injury providing a window of opportunity for the delivery of candidate therapeutic interventions. While high dose methylprednisolone steroid therapy alone has not proved to be the solution to this difficult clinical problem, other strategies for modulating inflammation and changing the make up of inhibitory molecules in the extracellular matrix are providing robust evidence that rehabilitation after spinal cord and brain injury has the potential to significantly change the outcome for what was once thought to be permanent disability.