A Porcine Model for Instruction of Lateral Canthotomy

OBJECTIVES: Retrobulbar hemorrhage is a rare condition often necessitating immediate lateral canthotomy for preservation of vision. It is performed infrequently in emergency departments (EDs); therefore, a laboratory-based curriculum using a swine model was developed to teach emergency medicine (EM) residents and pediatric emergency medicine (PEM) fellows the proper technique of lateral canthotomy and to provide them with hands-on training. METHODS: Anesthetized adult swine are used due to similarity with human anatomy and availability from other concurrent procedure laboratories. Fifteen to twenty milliliters of saline is injected behind the orbit to produce proptosis and mimic retrobulbar hemorrhage. A dissection is performed on one orbit to demonstrate the technique and to illustrate the lateral canthal ligaments. The resident then performs a rapid lateral canthotomy on the contralateral orbit under faculty supervision. ReSULTS: Over one year, 19 EM residents and 3 PEM fellows were trained using this model. During the same period no lateral canthotomies were performed in the EDs. A post-laboratory survey demonstrated a high subjective level of comfort with this procedure. Video-based demonstration of this laboratory is publicly available on the World Wide Web. CONCLUSION: Adult swine can effectively serve as a model for resident training in lateral canthotomy, a rarely performed sight-saving procedure.     

Evaluation of an Emergency-procedure Teaching Laboratory for the Development of Proficiency in Tube Thoracostomy

Objective : Emergency-procedure laboratories are not a standardized part of the curriculum for emergency medicine residency programs. The authors evaluated the efficacy of an emergency-procedure laboratory to teach medical students and residents the performance of tube thoracostomy.
Methods : A prospective repeated-measures study of tube thoracostomy placement training was performed in an animal-laboratory setting. Participants were six first-postgraduate-year emergency medicine residents and six fourth-year medical students. Each participant was given a written pretest on tube thoracostomies followed by lectures on tube thoracostomy, venous cutdown, peritoneal lavage, and surgical airway. The procedure laboratory, using an anesthetized canine model (20–25 kg), was then conducted. Tube thoracostomies were timed from skin incision to passage of the tube into the thoracic cavity with subsequent tube fogging. Four attempts per participant were documented. Eighteen days later, an identical procedure laboratory was conducted for the same students including a written posttest identical to the pretest.
Results : The written test scores improved for every participant (p < 0.0001). Mean times for procedures completion improved from 121 sec to 39 sec (p = 0<.001) during the first session and improved from 58 sec to 28 sec (p = 0.005) during the second session. Retention of skills was indicated by significant shortening of the time to completion from the first attempt of the first session to that of the second session (121 sec to 58 sec, p = 0.002).
Conclusions : This procedure laboratory, which emphasized skill repetition, led to improvement in procedural speed and retention of tube thoracostomy skills over time. This approach to teaching clinical procedures should be considered for emergency medicine residency programs and for continuing medical education courses that emphasize acquisition of clinical procedural skills.     

Emergency Department Resuscitative Procedures: Animal Laboratory Training Improves Procedural Competency and Speed

Certain resuscitative procedures can be lifesaving, but are performed infrequently by emergency medicine (EM) residents on human subjects. Alternative training methods for gaining procedural proficiency must be explored and tested. OBJECTIVE: To test whether animal laboratory training (ALT) is associated with sustained improvement in procedural competency and speed. METHODS: After watching an educational videotape of saphenous cutdown (SAPH), thoracotomy (THOR), and cricothyroidotomy (CRIC), EM residents were randomized to receive either a tutored ALT session on live anesthetized pigs (Group A) or no ALT session (Group B). Residents were tested six months later by performing procedures on live anesthetized pigs. Videotaped procedures were evaluated by blinded examiners for the number of critical steps, complications, and procedure times. RESULTS: Group A (n = 10) achieved a higher number of critical steps compared with Group B (n = 8) for SAPH (15.4 +/- 0.7 vs. 9.0 +/- 1.8, p = 0.03) and THOR (17.4 +/- 0.6 vs. 12.3 +/- 1.6, p = 0.009), but not CRIC (18.1 +/- 0.4 vs. 16.2 +/- 1.0, p = 0.1). Group A completed procedures in less time than Group B for SAPH (Wilcoxon chi(2) = 4.0, p = 0.04) and THOR (chi(2) = 4.4, p = 0.04), but not CRIC (chi(2) = 0.9, p = 0.3). There was no difference in the number of complications for any of the procedures. CONCLUSION: Residents with animal laboratory training six months prior to testing demonstrated improved procedural competency and speed in the performance of resuscitative procedures.     

Resident Service Hours in Emergency Medicine

Objective: The number of hours worked by residents in all specialties has become a controversial issue. Residents often are expected to competently conduct patient care activities and to take educational advantage of clinical experiences in spite of frequent fatigue and sleep deprivation. This survey of residency directors was designed to assess the scheduled clinical time for emergency medicine (EM) residents. Methods: A 13-question survey dealing with time commitments of EM residents was sent to the residency directors of all accredited EM residency programs in the United States in the fall of 1991. Residency directors were asked to indicate the number of shifts, hours, and days off per week; and the number of night shifts and weekend days off per month for each postgraduate year of residency training (PGY1-PGY4). Directors also were asked whether shifts were scheduled randomly or predictably with progression from days to nights with time off after nights. Results: Seventy of 71 (98.6% response rate) residency directors responded. Residents were scheduled for an average of 49.1 hours per week. Scheduled hours decreased from an average of 51.9 at the PGY1 level to an average of 44.5 at the PGY4 level. A similar progression with year of training was noted for scheduled night shifts/ month, days off/week, and weekend days off/month. A PGY1 trainee averaged 7.0 night shifts/month, 1.9 days off/week, and 3.0 weekend days off/month; while a PGY4 trainee averaged 5.3, 2.4, and 3.2, respectively. Only 40% of the directors reported predictable scheduling progressing from days to nights. Conclusion: Emergency medicine resident schedules, as reported by residency directors, fall well within current specialty-specific requirements and compare favorably with the reported numbers for other specialties. However, because large ranges in scheduling parameters were reported, the data may be of value to residency directors, residents, and prospective residents. Most programs did not report a predictable schedule progression of shifts.     

The Performance of Procedures on the Recently Deceased

OBJECTIVE: To determine the prevalence of performing procedures on the recently deceased for training purposes in emergency departments (EDs) with emergency medicine (EM) training programs. METHODS: Surveys were mailed to program directors of Accreditation Council for Graduate Medical Education (ACGME)-approved residency programs in EM. A check-off system was used to identify which procedures were performed and who performed the procedure. The survey also documented whether consent was obtained and whether written policies exist that address this issue. A Likert scale was used to evaluate respondents' attitudes toward this practice. RESULTS: Ninety-six (83%) of 116 surveys were returned. Forty-seven percent of the respondents indicated procedures were performed on the recently deceased for teaching purposes in their EDs. Emergency medicine residents perform the procedures in all departments where this practice occurs, with off-service residents and medical students using this technique in half of those departments. Paramedics, flight nurses, and attending physicians occasionally use this resource. Endotracheal intubation was the most commonly performed procedure. Seventy-six percent stated they "almost never" obtain consent from family members. Only four of 96 respondents have written policies concerning this practice. The majority of program directors (69%) would favor a position statement from a national EM organization concerning this issue, while 11% were opposed. CONCLUSIONS: The performance of procedures on the recently deceased is a common and important practice in EM training programs. Consent is infrequently obtained and policies concerning this practice are rare and restrictive when present.     

Procedure lab used to improve confidence in the performance of rarely performed procedures.

OBJECTIVES: The objective of this study is to assess the efficacy of an animal procedure lab in improving the level of comfort in performing important emergency medicine procedures. The procedures included central venous line, chest tube, cricothyrotomy, pericardiocentesis, venous cutdown, and thoracotomy. METHODS: The students were physicians participating in the Tuscan Emergency Medicine Initiative as part of a certificate program in emergency medicine. They attended a 1-h lecture discussing the procedures to be performed. Participants filled out a questionnaire before and after the lab, which asked how many times they had performed each procedure, how comfortable they felt, on a five-point scale, performing each procedure, and whether they felt comfortable performing it by themselves, with assistance or whether they would not feel comfortable performing the procedure. Differences in rated numerical values for each procedure before and after the lab were analyzed using a two-tailed t-test. Alpha was set at 0.95. RESULTS: In all, there were 20 participants with a wide range of experience. A statistical improvement was observed in comfort level and willingness to perform the procedures independently (P<0.01). The only non-significant change was in willingness to perform central lines. CONCLUSIONS: The use of an animal lab improves the comfort level of practitioners in performing procedures. Although procedures are best learned on patients with supervision, this is not always feasible. This lab is a useful adjunct to teaching in emergency medicine and allows participants exposure to critical procedures.     

Residents with disabilities: a national survey of directors of emergency medicine residency programs

BACKGROUND: The Americans With Disabilities Act (ADA) has been in effect since 1990. The present study shows response to this act for emergency medicine (EM) residents nationwide. METHODS: A total of 121 surveys were mailed to the directors of American College of Graduate Medical Education (ACGME)-approved residency programs. A definition of disability was provided, and a second mailing was sent to those not replying. RESULTS: Ninety-two program directors (76%) responded, representing 4,644 residents. Of these, 62 residents (1.3%) were reported as having a documented disability. Programs with a known disabled resident were significantly more likely to have available resources for assistance. Forty-seven (52%) of the program directors suspected a resident might have an undiagnosed disability, and 40 (85%) of these recommended testing or referral. CONCLUSIONS: There is a wide array of disabilities among EM residents. Available assistance varies. This may apply to other residencies as well.     

Emergency Medicine Resident Moonlighting: A Survey of Program Directors

OBJECTIVES: 1) To systematically describe emergency medicine (EM) program directors' perceptions of the benefits and risks of resident moonlighting. 2) To assess moonlighting policies of EM residencies, the degree of compliance with these policies, and the methods of dealing with residents who are out of compliance. METHODS: A written survey was mailed or hand-delivered to all allopathic and osteopathic EM residency directors in the United States in 1992-93. Incomplete and ambiguous surveys were completed by phone. RESULTS: There was a 96% response rate (113/118). The average EM resident clinical workweek ranged from 38 to 50 hours while the resident was assigned to ED rotations. Most (90%) of the program directors believe moonlighting interferes with residency duties to some degree. Few (10%) programs prohibit moonlighting altogether, although 44% limit moonlighting to an average of 41.5 hours per month. Program directors believe residents moonlight primarily for financial reasons. Most (60%) of the program directors believe moonlighting offers experience not available in the residency, primarily related to autonomous practice. Fifteen programs reported residents who had been sued for malpractice while moonlighting, with one program director named along with the resident. One third of program directors have penalized residents for abuse of moonlighting privileges. CONCLUSIONS: EM residency directors are concerned about the effect of moonlighting on resident education. The directors' concerns regarding litigation, excessive work hours, and interference with residency duties are balanced by a general acceptance of the financial need to supplement residency income.     

Musculoskeletal education in physical medicine and rehabilitation residency programs: graduating resident perspective

OBJECTIVES: To characterize graduating physical medicine and rehabilitation (PM&R) residents physicians' perceptions of their current musculoskeletal (MSK) training, to identify barriers perceived by resident physicians to improving MSK education experiences, and to compare the views of resident physicians with those of PM&R residency program directors. DESIGN: Fourth-year PM&R residents graduating in 2004 whose program directors attended the 2004 Association of Academic Physiatrists annual meeting were asked to complete an MSK education survey developed by the authors. Data were compared with a previous MSK education survey that had been completed by PM&R residency program directors. RESULTS: Ninety-three of 156 (61%) fourth-year PM&R residents responded after multiple contacts. According to residents, the most frequently used MSK education formats during residency were MSK lecture series, MSK journal clubs, and MSK workshops. Potential barriers to improved MSK education during residency included staff, money, and time. If given unlimited resources, most residents would greatly increase the use of visiting lecturers, MSK workshops, and MSK lecture series. CONCLUSION: Graduating PM&R residents as well as residency program directors indicated a strong interest in expanding resident MSK education through the use of visiting lecturers. Differences were noted with respect to the use of hands-on learning (i.e., MSK workshops [residents]) vs. passive learning (i.e., CD ROMS/DVDs and videos [program directors]). Both groups described how limited resources including staff, money, and time are barriers to resident MSK education.     

Report from the Council of Emergency Medicine Residency Directors Subcommittee on Graduate Medical Education Funding: Effects of Decreased Medicare Support

INTRODUCTION: Recent changes by the Health Care Financing Administration (HCFA) have resulted in decreased Medicare support for emergency medicine (EM) residencies. OBJECTIVE: To determine the effects of reduced graduate medical education (GME) funding support on residency size, resident rotations, and support for a fourth postgraduate year (PGY) of training and for residents with previous training. METHODS: A 36-question survey was developed by the Council of Emergency Medicine Residency Directors (CORD) committee on GME funding and sent to all 122 EM program directors (PDs). Responses were collected by the Society for Academic Emergency Medicine (SAEM) office and blinded with respect to the institution. RESULTS: Of 122 programs, 109 (89%) responded, of which 78 were PGY 1-3 programs, 19 were PGY 2-4, and 12 were PGY 1-4. The PDs were asked specifically whether there were changes in program size due to changes in Medicare reimbursement. Although few programs (12%) decreased their size or planned to decrease their size, 39% had discussions regarding decreasing their size. Thirty percent of the PDs responded that other programs at their institution had already decreased their size; 26% of the PDs had problems with financing outside rotations; and 24% had a decrease in off-service residents in their emergency departments (EDs). Only seven (6%) of programs paid residents from practice plan dollars, while most (82%) were fully supported by federal GME funding. Nearly all four-year programs (97%) received full resident salary support from their institutions and 77% of programs accept residents with previous training. CONCLUSIONS: Nearly all EM programs are fully supported by their institutions, including the fourth postgraduate year. Most programs take residents with previous training. Although few programs have reduced their size, many are discussing this. Many programs have had difficulty with funding off-service rotations and many have had decreased numbers of off-service residents in their EDs. Recent GME funding changes have had adverse effects on EM residency programs.     

Procedure Documentation in Emergency Medicine Residencies: A Time of Change

Objectives: The purpose of this study was to identify the methods of procedure documentation (PD) used by emergency medicine residency programs and to ascertain the number of programs that are transitioning to a more advanced system. Methods: All 122 ACGME-approved allopathic emergency medicine programs were contacted by telephone in December 2001. Survey information was obtained from the program director, an attending physician, a resident, or the residency coordinator. Results: The response rate was 92.6%. Seventeen programs (15%) reported using multiple methods of PD, with only 8% utilizing a formal database. Fifty-five percent reported that PD was manual. One third of all programs utilized a Web-based system for PD, while 13% required the use of personal digital assistants (PDAs). Nearly one fifth of programs stated they were changing to another form of PD, with the majority of those changing to a PDA format. Fifteen percent of programs purchased PDAs for their residents, and a similar proportion reported that the PDA was used by "most or all" of their residents to document procedures. Nearly four times as many programs (64%) reported that "most or all" of their residents utilized PDAs for clinical purposes. Conclusions: PDAs are used by a majority of residents for clinical purposes, although fewer utilize this resource for PD. Although most emergency medicine residency programs still utilize a manual system for PD, many programs are in transition to a more technologically advanced method.     

Perceptions of emergency medicine residents on the quality of residency training in the United States and Saudi Arabia

BACKGROUND: We compare educational environments (i.e. physical, emotional and intellectual experiences) of emergency medicine (EM) residents training in the United States of America (USA) and Saudi Arabia (SA).METHODS: A cross-sectional survey study was conducted using an adapted version of the validated Postgraduate Hospital Educational Environment Measure (PHEEM) survey instrument from April 2015 through June 2016 to compare educational environments in all emergency medicine residency programs in SA and three selected programs in the USA with a history of training Saudi physicians. Overall scores were compared across programs, and for subscales (autonomy, teaching, and social Support), using chi-squared, t-tests, and analysis of variance. RESULTS: A total of 219 surveys were returned for 260 residents across six programs (3 SA, 3 USA), with a response rate of 84%. Program-specific response rates varied from 79%-100%. All six residencies were qualitatively rated as “more positive than negative but room for improvement”. Quantitative PHEEM scores for the USA programs were significantly higher: 118.7 compared to 109.9 for SA, P=0.001. In subscales, perceptions of social support were not different between the two countries (P=0.243); however, role autonomy (P<0.001) and teaching (P=0.005) were better in USA programs. There were no significant differences by post-graduate training year. CONCLUSION: EM residents in all three emergency medicine residency programs in SA and the three USA programs studied perceive their training as high quality in general, but with room for improvements. USA residency programs scored higher in overall quality. This was driven by more favorable perceptions of role autonomy and teaching. Understanding how residents perceive their programs may help drive targeted quality improvement efforts.     

Emergency Medicine Resident Rotation in Pediatric Emergency Medicine: What Kind of Experience Are We Providing?

OBJECTIVES: To characterize emergency medicine (EM) residents' clinical experience during a pediatric emergency medicine (PEM) rotation. METHODS: Prospective observational study of EM resident-patient encounters in a children's hospital emergency department (ED). RESULTS: Fifty-six residents participated in the study. The mean (+/-SD) patient age was 6.3 (+/-5.6) years. Ambulatory infectious disease, respiratory illness, and wound management represented almost 50% of final diagnoses. Six and a half procedures/resident were performed per rotation, mainly nonemergent procedures, whereas resuscitations and child abuse evaluations were rare. A minority of patients required data interpretation: 34.4% had laboratory testing, 24.6% had radiographic studies, and 2.3% had electrocardiograms. CONCLUSIONS: Analysis of patient encounters during a PEM rotation showed deficiencies in critical care procedures, resuscitations, child abuse evaluations, and neonatal evaluations. Quantitative data of skills utilized during rotations can be used by residency programs to identify and correct deficiencies in their residents' PEM education.     

Rehabilitative rheumatology content in current rehabilitation medicine training programs

The Council on Rehabilitative Rheumatology of the American Rheumatism Association, through the Education Subcommittee, surveyed directors of 69 approved rehabilitation medicine residency training programs to assess the nature of training in rehabilitative-rheumatology and whether the directors believed this training to be adequate. Sixty-one directors responded, with 84% of the respondents reporting a rheumatology department in their hospitals and 43% reporting a formal rotation for their residents in rheumatology. Fifty-nine (97%) reported their residents received lectures in rheumatology. Fifty-five (90%) reported lectures given by a physiatrist in the rehabilitative management of rheumatic diseases. Only 21 (34%) reported a physiatrist-attended rheumatology outpatient clinic. Fifty-one (82%) desired a closer liaison with the rheumatology department. Thirty-seven (61%) indicated their residents received adequate training on the diagnosis of rheumatic diseases, and 46 (75%) adequate training in rehabilitative management, while 59 (97%) desired a concise handbook which emphasizes the rehabilitative management of rheumatic diseases. A previous survey of 100 arthritis fellowship programs approved by the American Medical Association brought 81 responses, of which only 43% considered that their Fellows had adequate training in rehabilitative rheumatology. Physiatrists attended clinics 21% of the time and patient care rounds 19%. Ninety-four percent desired a syllabus. Both surveys indicated limited interaction between the two specialties and leads us to conclude that a rehabilitative-rheumatology handbook would be desirable, closer liaison of rehabilitation faculty with rheumatology faculty is needed to respond to individual training needs, more active participation by a physiatrist in patient care conferences may be necessary for adequate education in rehabilitative-rheumatology.     

Clinical procedures performed by emergency medicine resident physicians: a computer-based model for documentation

To facilitate documentation and assess the number and types of clinical procedures actually performed by resident physicians, we developed a microcomputer-based recording process. After completing a procedure, including resuscitations, residents recorded in a precoded book issued for each monthly rotation. At the end of each rotation, the books were collected and the information was transferred to a database program by the clerical staff. During 1989, 17 emergency medicine resident physicians at PGY levels 1 through 3 utilized this system. Completed procedure record books were submitted for 124 of 148 clinically active months for a compliance rate of 84%. Of 1,857 procedures recorded, the most frequent were resuscitation (20%), orotrachael intubation (12%), and percutaneous central vein cannulation (12%). Commonly recorded were lumbar puncture (7%), diagnostic peritoneal lavage (5%), nasotrachael intubation (4%), and newborn delivery (4%). The high compliance rate suggests resident physicians acceptance. This system enables residency directors to closely monitor individual and group procedure experiences and to make curriculum changes based on objective findings. It also provides a means of storing and retrieving data for review organizations and credentials committees.     

Assessing clinical competence in physical medicine & rehabilitation residency programs

OBJECTIVE: Evaluation of resident clinical competence is a complex task. A multimodal approach is necessary to capture all of the dimensions of competence. Recent guidelines from the Accreditation Council for Graduate Medical Education delineate six general competencies that physicians should posses. Application of these guidelines presents challenges to residency program directors in defining educational experiences and evaluation methods. DESIGN: We surveyed 81 physical medicine and rehabilitation program directors regarding assessment tools used in their programs. Seventy-five percent responded. The most frequently used assessment tools included: In-training self-assessment examinations, faculty evaluations, direct observation, and conference participation. Program directors assigned the highest values to direct observation, faculty evaluations, self-assessment examinations, and oral examinations. RESULTS: Of the general competencies, more than 90% of program directors believed they did an adequate job rating dimensions of patient care, medical knowledge, professionalism, and communication skills. Approximately one-third, however, thought they did a less than fair job rating practice-based learning and improvement and systems-based practice. The majority of programs reported that they were able to identify a resident with difficulties during the first year of training, 44% within the first 6 months. Program directors reported that their residents spend a significant amount of their time with nurses and therapists during their inpatient rotations; however, this was not reflected in their evaluation practices, in which only one-fourth of programs reported the use of nurses and therapists in evaluating residents. CONCLUSIONS: Survey results indicate that physical medicine and rehabilitation program directors apply a variety of assessment tools in evaluating resident clinical competence. Although perceptions about the relative value of these tools vary, most programs report a high value to direct observation of residents by faculty. Of the six general competencies, program directors struggle the most with their evaluation of practice-based learning and improvement and systems-based practice.