Survey of Emergency Medical Services Curricula in U.S. Emergency Medicine Residencies

Some areas of EMS instruction are more consistently offered in residency programs than in the past. Formal (structured) preparation for the provision of OLMC has become almost universal, while involvement in quality-related activities and training in the areas of risk management and EMS administration appear to have increased. However, resident involvement in disaster activities has decreased in recent years, and there is still much variability between programs in the extent and scope of EMS teaching. Field experiences still vary widely, for both ground and air services.     

Pediatric Pain Control and Conscious Sedation: A Survey of Emergency Medicine Residencies

Objective : To determine the availability and relative use of pediatric analgesia and sedation at sites of U.S. emergency medicine residency training programs.
Methods : A mail/telephone survey of residency directors at 80 U.S. emergency medicine residencies regarding resident experience with pediatric analgesia and sedation for painful procedures conducted during November 1991.
Results : Sixty of 80 surveys (75%) were completed and available for analysis. Emergency medicine faculty supervised conscious sedation and analgesia in 87% of responding programs, while pediatrics faculty and pediatrics-emergency medicine fellows supervised in the remainder. Ninety-three percent of the programs had sedating agents available in the emergency department; only four programs needed to have drugs brought from the pharmacy. Thirty-four programs (57%) had formal protocols for the administration of these drugs. Seventy-seven percent of the programs had airway resuscitation equipment at the bedside, while only 63% brought resuscitation drugs. However, 60% of the programs reported complications of sedation, including respiratory depression, prolonged sedation, agitation, and vomiting. The most commonly used agents were midazolam (82%), meperidine alone (68%) and with promethazine and chlorpromazine (67%), and chloral hydrate (67%). Only 25% of the programs used nitrous oxide, and 30% used ketamine.
Conclusions : Emergency medicine residencies generally have available agents for pain control and conscious sedation in children, although the agents used vary widely. Appropriate instruction by trained faculty should enhance resident experience with pediatric pain control and sedation.     

Impact of Emergency Medicine Faculty and an Airway Protocol on Airway Management

OBJECTIVE: To determine the impact of emergency medicine (EM) faculty presence and an airway management protocol on success rates of tracheal intubation in the emergency department (ED). METHODS: A retrospective observational study of prospectively collected data on rates of successful intubations between June 1997 and December 2001 in the ED of a large urban teaching hospital. The authors compared success rates of the first attempt at intubation and times to intubation prior to and after EM faculty presence and the institution of an airway management protocol. RESULTS: Prior to EM faculty presence and the airway management protocol, tracheal intubation was achieved on the first attempt 46% of the time; more than six attempts were required 2.9% of the time. The mean time to intubation was 9.2 minutes (+/-13.2 SD). Following EM faculty presence and the airway protocol, the success rate on the first attempt was 62%, more than six attempts were required 1.1% of the time, and the mean time to intubation was 4.6 minutes (+/-6.2 SD). CONCLUSIONS: First-attempt intubation success rates and decreased mean time to successful intubation improved following EM faculty presence and the introduction of an airway management protocol.     

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.     

Trauma Airway Management: Transition from Anesthesia to Emergency Medicine

Background

Trauma airway management is commonly performed by either anesthesiologists or Emergency Physicians (EPs).

Objective

Our aim was to evaluate the impact of switching from one group of providers to the other, focusing on outcomes and complications.

Methods

Medical records were used to identify all patients during a 3-year period who were intubated emergently after traumatic injury. Before November 1, 2007, airway management was supervised by anesthesiologists, after that date airways were supervised by EPs. Complications evaluated included failure to obtain a secure airway, multiple attempts at airway placement, new or worsening hypoxia or hypotension during the peri-intubation period, bronchial intubations, dysrhythmia, aspiration with development of infiltrate on chest x-ray study within 48 h, and facial trauma.

Results

Of the 490 tracheal intubations, 250 were attended by EPs and 240 were attended by anesthesiologists. The groups were well matched with respect to age and sex, but the EP group treated more severely injured patients on average. Intubation was accomplished in one attempt 98.3% of the time in the anesthesia group; those requiring multiple attempts went on to need surgical airways 2.1% of the time. EPs accomplished intubation in one attempt 98.4% of the time, with an overall success rate of 96.8%; surgical airways were needed in 3.2% of patients. The complication rate was 18.3% for the anesthesia group and 18% for the EP group. There were no statistically significant differences between the EP and anesthesia groups with regard to complication rates, although the EP patients had a higher Injury Severity Score on average.

Conclusions

EPs can safely manage the airways of trauma patients with rates of complication and failure comparable with those of anesthesiologists.     

Manual of Emergency Airway Management

Abstract. By Ron M. Walls, Robert C. Luten, Michael F. Murphy, and Robert E. Schneider. Philadelphia: Lippincott Williams & Wilkins, 2000; 256 pp; $42.95 (softcover).     

我国气道管理现状调查

  目的  针对我国气道管理的现状进行问卷调查, 为改进和完善我国气道管理提供参考。  方法  采用邮寄调查问卷的方法, 对全国27个省市自治区78家医院进行调查。调查问卷包括被调查者基本情况, 对各种气道工具的熟知和使用程度, 对临床几种气道情景的处理以及科室气道管理等4个部分。以教学和非教学医院为分组变量, 采用校正χ²检验进行分析比较。  结果  调查问卷有效回收率为60.7%。所有麻醉医师最熟悉且能熟练使用的是Macintosh喉镜片、标准镜柄、口咽通气道和塑形管芯。教学医院麻醉医师对视频喉镜Glidescope、可视管芯、插管型喉罩及纤维支气管镜的了解和熟练使用与非教学医院比较差异有显著统计学意义(P < 0.01)。对其他气道工具, 包括紧急气道工具的了解和使用教学与非教学医院差异较大。对有明确插管困难的患者, 近半数麻醉医师(46.9%)选择纤维支气管镜下清醒插管; 79.2%的麻醉医师遇到意外插管困难时能在维持通气时尝试其他方法; 遇到不能通气不能插管时, 首选喉罩改善通气和环甲膜穿刺建立气道的麻醉医师分别为47.6%和52.4%;怀疑有插管困难, 绝大多数麻醉医师(92.6%)会先尝试麻醉后直接喉镜插管。教学医院在建立简便气道处理流程、专业团队建设和培训上比非教学医院好(P < 0.01)。  结论  被调查的麻醉医师对气道管理工具的认识和使用差异较大, 但对气道处理流程的遵循较好。麻醉科室在气道管理方面仍有需改善之处。     

National Survey of Emergency Medicine Resident Moonlighting

OBJECTIVES: To survey emergency medicine (EM) residents regarding moonlighting practices and perceptions for clarifying: 1) resident moonlighting remuneration; 2) any association of perceived educational debt with moonlighting income and hours; and 3) perceptions related to moonlighting (including motivations, impact on resident training, and potential medicolegal difficulties). METHODS: A confidential, voluntary survey was administered to all allopathic EM residents in the United States. This written survey was provided to residents at their in-service examinations. Completed forms were anonymously returned by residents or local administrative staff to a central site where all identifiers were removed prior to mailing en mass to the investigators. Comparisons between groups were made using chi-square tests and correlations were assessed using the Pearson correlation coefficient. RESULTS: Seventy-six percent (1,826/2,407) of the surveys were returned. There was a weak correlation (r = 0.11) between educational debt and moonlighting hours for residents in the second year and above, but no association of debt with moonlighting income. Most (88%) of the residents reported that their programs permitted moonlighting. Nearly half (49%) reported that they did moonlight in some way. Most (82%) thought moonlighting provided experience not available in the residency. Only 13 (2%) respondents stated they had been sued for malpractice while moonlighting. Most (66%) moonlighting respondents stated that they moonlighted for financial reasons, with educational debt the primary motivating factor. Of the moonlighting residents, 28% were unsure of their type of malpractice insurance coverage, and 9% had no coverage at all. CONCLUSIONS: Education about EM practice matters including the risks of moonlighting should begin early in residency, because moonlighting is widespread. Residents are vulnerable to medicolegal action while moonlighting and have insufficient knowledge of their malpractice insurance coverage. Although educational debt is perceived as a strong motivating factor for moonlighting, there is only a weak relationship between educational debt and moonlighting hours.