A longitudinal study of residency-trained emergency physicians

An annual survey of emergency medicine (EM) graduate physicians from 31 programs was conducted from 1977 through 1979. Results of the 1979 data are presented. Practice patterns show that 96% of the EM graduates are providing patient care, and almost half are working in the states in which they trained. Of those caring for patients, 38.8% practice in an urban location and only 7% work in rural hospitals. Learning new skills and procedures and retaining skills are major problems faced by physicians in rural locations. Other activities of EM graduates include teaching medical students and residents, administration, research, and community emergency medical services. Data are analyzed with attention to long-term commitment to emergency medicine. Implications for manpower needs are suggested.     

A novel emergency medical services-based program to identify and assist older adults in a rural community

Rural-dwelling older adults experience unique challenges related to accessing medical and social services. This article describes the development, implementation, and experience of a novel, community-based program to identify rural-dwelling older adults with unmet medical and social needs that leveraged the existing emergency medical services (EMS) system. The program specifically included geriatrics training for EMS providers; screening of older adult EMS patients for falls, depression, and medication management strategies by EMS providers; communication of EMS findings to community-based case managers; in-home evaluation by case managers; and referral to community resources for medical and social interventions. Measures used to evaluate the program included patient needs identified by EMS or the in-home assessment, referrals provided to patients, and patient satisfaction. EMS screened 1,231 of 1,444 visits to older patients (85%). Of those receiving specific screens, 45% had fall-related, 69% medication management-related, and 20% depression-related needs identified. One hundred and seventy-one eligible EMS patients who could be contacted accepted the in-home assessment. Of the 153 individuals completing the assessment, 91% had identified needs and received referrals or interventions. This project demonstrated that screening by EMS during emergency care for common geriatric syndromes and linkage to case managers is feasible in this rural community, although many will refuse the services. Further patient evaluations by case managers, with subsequent interventions by existing service providers as required, can facilitate the needed linkages between vulnerable rural-dwelling older adults and needed community-based social and medical services.     

An emergency medical services program to promote the health of older adults

OBJECTIVES: To evaluate the feasibility and effect of an emergency medical services (EMS) program that screened, educated, and referred older adults with unmet needs. DESIGN: A cluster sample design evaluation of an intervention conducted by EMS in one of two communities. SETTING: Two rural communities in upstate New York. PARTICIPANTS: Two hundred fifty-eight intervention-group and 143 control-group community-dwelling older adults receiving emergency care from participating EMS agencies between February 2004 and June 2005. INTERVENTION: EMS providers screened intervention group patients to identify those at risk for falls, influenza, and pneumococcal infections and provided patients educational materials. Patients' physicians were notified of screening results to provide interventions. Control group patients were provided usual care. MEASUREMENTS: Variables included patient demographic and clinical characteristics, the proportion of eligible patients screened, patient risk during EMS care and 14 days later, and patient recollection of receiving educational materials and conversations with physicians regarding needs. RESULTS: Follow-up was successful in 245 (61%) patients. Approximately 80% of intervention-group patients were successfully screened for each item. No differences were identified for characteristics collected at the time of EMS care, but a notable number of patients were at risk for each item. No differences existed between the control or intervention group for process measures such as recollection of receiving educational materials. For outcome measures, only an improvement in pneumococcal vaccination levels was found. CONCLUSION: EMS screening of older adults during emergency responses is feasible, but a simple intervention of providing educational materials to patients during emergency responses and faxing notifications to physicians appears insufficient to address patients' needs.     

A computer-assisted quality assurance system for an emergency medical service

A busy urban emergency medical service answering more than 50,000 calls each year developed a plan for quality assurance using a computer-assisted model designed to employ a full-time quality assurance officer whose work was supplemented with computer evaluation of EMS field reports. The development of standardized reporting formats, protocols and computer programs enabled a significant improvement in detection of errors of documentation and patient care. Investigated cases rose dramatically in the month following implementation of the system, from five patient care errors per month to 35 (P less than .05), and from 50 documentation errors to 265 per month (P less than .05). Our experience indicates that computer-assisted evaluation of field performance, as judged by prehospital records, is a useful tool to ensure standards in patient care and EMS recordkeeping.     

Rural trauma care: a study of trauma care in a rural emergency medical services region

Motor vehicle-related trauma deaths in a 21-county rural emergency medical services (EMS) system are reviewed. Injury severity scores (ISS) and Glasgow coma scores (GCS) were recorded to provide baseline data for future comparison as the system progresses. The majority of deaths (67%) were related to CNS injuries. ISS in this series was similar to data reported from Orange County, California. The average GCS for all patients in this series was 5, indicating the high prevalence and severity of head injuries in motor vehicle deaths. Patients treated only in community hospitals had a low average ISS of 28.5. Those transferred from community hospitals to the regional tertiary care center had an average ISS of 36.2. Those admitted directly to the tertiary center had an ISS of 38.9. The data suggest that the rural trauma system might improve if there were training programs that promote recognition of significant injury, more aggressive resuscitation, and expeditious transfer of the injured patients.     

The effect of the geriatrics education for emergency medical services training program in a rural community

The Geriatrics Education for Emergency Medical Service (EMS) (GEMS) course provides continuing education for EMS providers. This study evaluated the effect of the course on EMS providers in a rural county by performing a prospective cohort study using a pre-postsurvey design. The Geriatric Attitude Scale, the GEMS knowledge posttest, a class satisfaction survey, and a survey evaluating EMS providers' comfort in caring for older adults were used to measure the classes' effect. Eighty-eight EMS providers participated. All passed the course and were very satisfied with it. Follow-up was completed with 77 (80%). No significant change in attitude score was identified ( P =.09). Median comfort scores significantly increased for the domains of communications, medical care, abuse evaluation, and falls evaluation. Providing the GEMS course to EMS providers in a rural community resulted in students passing a posttest evaluating their knowledge regarding caring for older adults and resulted in an increase in their comfort level for the care of older adults. The effect of the training on patient outcomes needs to be identified.      

Emergency Medical Service Attitudes Toward Geriatric Prehospital Care and Continuing Medical Education in Geriatrics

OBJECTIVES: To understand the opinions of emergency medical service (EMS) providers regarding their ability to care for older adults, the domains of geriatric medicine in which they need more training, and the modality through which continuing education could be best delivered.
DESIGN: Qualitative study using key informant interviews.
SETTING: Prehospital EMS system in Rochester, New York.
PARTICIPANTS: EMS providers, EMS instructors and administrators, emergency physicians, and geriatricians.
MEASUREMENTS: Semistructured interviews were conducted using an interview guide that addressed knowledge and skill deficiencies, recommendations for improvement of geriatrics continuing education, and delivery methods of education.
RESULTS: Participant responses were generally congruous despite the diverse backgrounds, and redundancy was achieved rapidly. All participants perceived a deficit in EMS education on the care of older adults, particularly related to communications with patients and skilled nursing facility staff. All desired more geriatric continuing education for EMS providers, especially in communications and psychosocial issues. Education was desired in various modalities.
CONCLUSION: Further geriatric continuing education for EMS providers is needed. Some specific topics relate to medical issues, but a large proportion involve communications and psychosocial issues. Education should be delivered in a variety of modalities to meet the needs of the EMS community. Emerging on-line video technologies may bridge the gap between learners preferring classroom-based modailities and those preferring self-study modules.     

Role of the physician in the prehospital setting

Despite the initial successes achieved in early emergency medical services (EMS) systems, many prehospital care services have developed without the intense involvement of physicians whose interest fueled the first experimental medical programs of prehospital care. Among a myriad of variables affecting EMS is the important element of intense, authoritative physician involvement in education, field supervision, and research. Recognizing this problem, many states now have legislated that EMS systems be closely supervised by medical directors. Political and financial constraints often have diluted medical influence and authority, and intense, direct field supervision is the exception rather than the rule. successful EMS systems can demonstrate their influence on morbidity and mortality through appropriate data collection and quality assurance programs. Such programs appear to have in common the element of direct involvement of competent physicians in initial training, field supervision, and policy decisions. Until recently, full-time compensated physician involvement in EMS has been regarded as unnecessary or impractical. Certainly in large urban centers such full-time involvement is mandatory. While in smaller municipalities full-time commitments may be unnecessary, partial compensation for time dedicated to EMS pursuits should be part of the EMS budget. It has been the experience of major urban EMS systems that field participation by physicians has lent irrefutable credibility to the authority of medical directors. Beyond the obvious benefits of quality assurance and supervision, the in-field EMS physician provides the impetus and leadership for EMS research conducted at the street level. Because EMS is the practice of medicine through physician surrogates in a prehospital setting, it sets the stage and tone for subsequent patient care and outcome.(ABSTRACT TRUNCATED AT 250 WORDS)     

Monitoring ems protocol deviations: A useful quality assurance tool

STUDY OBJECTIVE: To determine the incidence, type, and outcome of protocol deviations in an emergency medical services (EMS) system. DESIGN: Retrospective consecutive case series. SETTING: Seven advanced life support ambulance services servicing five area hospital emergency departments. PATIENTS: 1,246 patients requiring advanced life support care. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Advanced life support ambulance runs during a two-month period were examined for protocol deviations. Of 1,246 runs examined, 16% had deviations. Approximately 55% of these deviations were minor, 38% were serious, and 7% were very serious in nature. The effects of the errors were evaluated using hospital records. Results showed that 89.5% of patients were unaffected, 5.0% improved, and 5.5% suffered complications from deviations. Emergency medical technicians committed 69% of the deviations without the consent of medical control, medical control committed an additional 18%, and both were responsible in 13% of cases. Incomplete histories were found in 8% of cases. CONCLUSION: Protocol deviations committed in prehospital care do not usually cause direct harm to patients. On review of these deviations, however, several disturbing trends were uncovered, including misconceptions in the use of IV therapy, a number of serious deviations in advanced cardiac life support protocols, and lack of communication with medical control. This type of quality assurance study has the ability to identify areas of strength and weakness in an EMS system, allowing planning of ongoing educational efforts in the system.     

High-fidelity simulation is associated with good discriminability in emergency medicine residents’ in-training examinations

In-training examinations (ITEs), arranged during residency training, evaluate the residents’ performances periodically. There is limited literature focusing on the effectiveness of resident ITEs in the format of simulation-based examinations, as compared to traditional oral or written tests. Our primary objective is to investigate the effectiveness and discriminative ability of high-fidelity simulation compared with other measurement formats in emergency medicine (EM) residency training program.This is a retrospective cohort study. During the 5-year study period, 8 ITEs were administered to 68 EM residents, and 253 ITE measurements were collected. Different ITE scores were calculated and presented as mean and standard deviation. The ITEs were categorized into written, oral, or high-fidelity simulation test forms. Discrimination of ITE scores between different training years of residency was examined using a one-way analysis of variance test.The high-fidelity simulation scores correlated to the progression of EM training, and residents in their fourth training year (R4) had the highest scores consistently, followed by R3, R2, and then R1. The oral test scores had similar results but not as consistent as the high-fidelity simulation tests. The written test scores distribution failed to discriminate the residents’ seniority. The high-fidelity simulation test had the best discriminative ability and better correlation between different EM residency training years comparing to other forms.High-fidelity simulation tests had the good discriminative ability and were well correlated to the EM training year. We suggest high-fidelity simulation should be a part of ITE in training programs associated with critical or emergency patient cares.     

Cost-effectiveness analysis of paramedic emergency medical services in the treatment of prehospital cardiopulmonary arrest

STUDY OBJECTIVES: 1) Identification of marginal costs associated with prehospital resuscitation of cardiopulmonary arrest; 2) Determination of cost effectiveness for such resuscitation; and 3) Comparison of cost effectiveness of paramedic care with selected other medical interventions. DESIGN: Retrospective review of 190 cases of out-of-hospital cardiac arrest. SETTING: City limits of a midsized southwestern city. The events studied took place outside of medical facilities. TYPE OF PARTICIPANTS: Victims of out-of-hospital cardiac arrest for whom the EMS system was activated by a 911 telephone request for emergency medical assistance. MEASUREMENTS AND MAIN RESULTS: The cost, including training, personnel, equipment, and response time maintenance, per year of life saved was found to be $8,886.00 for paramedic care. This result was compared with published cost-effectiveness figures for heart transplantation, liver transplantation, bone marrow transplantation, and chemotherapy for acute leukemia. Paramedic care was more cost effective, as measured by cost per year of life saved, than organ transplantation and chemotherapy for acute leukemia. CONCLUSION: Out-of-hospital treatment by paramedics of cardiopulmonary arrest is more cost effective than heart, liver, bone marrow transplantation, or curative chemotherapy for acute leukemia.     

Evaluation of EMS management training offered during emergency medicine residency training

Physician involvement in the provision of both direct and indirect medical control to emergency medical providers is critical to the effective operation of an emergency medical services (EMS) system. We conducted a survey of all accredited emergency medicine residency programs in the United States to determine the content of EMS instruction provided to these physicians-in-training. The majority of programs provide an introduction to direct medical control, to EMS organizational structure, and the opportunity to participate in EMS-related research. Less than 65%, however, provide formal instruction in EMS risk management or quality assurance or the opportunity to observe policy-making bodies related to EMS. The importance placed on EMS during residency training is variable. EMS is the domain of emergency medicine, and adequate training of residents for these responsibilities is imperative.     

An innovative emergency transportation scenario for mass casualty incident management: Lessons learnt from the Formosa Fun Color Dust explosion

The purpose of this research is to analyze and introduce a new emergency medical service (EMS) transportation scenario, Emergency Medical Regulation Center (EMRC), which is a temporary premise for treating moderate and minor casualties, in the 2015 Formosa Fun Color Dust Party explosion in Taiwan. In this mass casualty incident (MCI), although all emergency medical responses and care can be considered as a golden model in such an MCI, some EMS plans and strategies should be estimated impartially to understand the truth of the successful outcome.Factors like on-scene triage, apparent prehospital time (appPHT), inhospital time (IHT), and diversion rate were evaluated for the appropriateness of the EMS transportation plan in such cases. The patient diversion risk of inadequate EMS transportation to the first-arrival hospital is detected by the odds ratios (ORs). In this case, the effectiveness of the EMRC scenario is estimated by a decrease in appPHT.The average appPHTs (in minutes) of mild, moderate, and severe patients are 223.65, 198.37, and 274.55, while the IHT (in minutes) is 18384.25, 63021.14, and 83345.68, respectively. The ORs are: 0.4016 (95% Cl = 0.1032–1.5631), 0.1608 (95% Cl = 0.0743–0.3483), and 4.1343 (95% Cl = 2.3265–7.3468; P < .001), respectively. The appPHT has a 47.61% reduction by employing an EMRC model.Due to the relatively high appPHT, diversion rate, and OR value in severe patients, the EMS transportation plan is distinct from a prevalent response and develops adaptive weaknesses of MCIs in current disaster management. Application of the EMRC scenario reduces the appPHT and alleviates the surge pressure upon emergency departments in an MCI.     

A comparison between the efficacy of lectures given by emergency and non-emergency physicians in an international emergency medicine educational intervention

OBJECTIVE: The Tuscan Emergency Medicine Initiative is an international collaboration designed to create a sustainable emergency medicine training and qualification process in Tuscany, Italy. Part of the program involves training all emergency physicians currently practicing in the region. This qualification process includes didactic lectures, clinical rotations and practical workshops for those with significant emergency department experience. Lectures in the didactic portion were given by both emergency medicine (EM) and non-EM faculty. We hypothesized that faculty who worked clinically in EM would give more effective lectures than non-EM faculty. METHODS: Fifty-one emergency physicians from the hospitals surrounding Florence completed the course, which included 48 one-hour lectures. Twenty lectures were given by practicing emergency physicians and 28 were given by non-EM faculty. Participants completed an evaluation at the end of each session using a 5-point Likert scale describing the pertinence of the lecture to EM, the efficacy and clarity of the presentation, the accuracy of the information and the didactic ability of the lecturer. RESULTS: A mean of 38.5 evaluations was completed for each lecture. Every factor was significantly higher for lectures given by EM faculty: the pertinence of the lecture to EM (4.46 vs. 4.16, p < 0.001), the efficacy of the faculty (4.10 vs. 3.91, p < 0.001), the accuracy of the lecture content (4.16 vs 3.96, p < 0.001), and the didactic ability of the instructors (4.02 vs. 3.85, p = 0.001). CONCLUSIONS: When teaching EM, evaluations of lectures in this training intervention were higher for lectures given by EM faculty than by non-EM faculty.     

Utilisation of emergency medical service among Singapore patients presenting with ST‐segment elevation myocardial infarction: prevalence and impact on ischaemic time

Background: Previous studies in Western countries found that the emergency medical service (EMS) was under‐used in patients with myocardial infarction. Aim: We sought to determine the prevalence of immediate EMS utilisation among Singapore patients presenting with ST‐segment elevation myocardial infarction (STEMI), and correlated the use of the EMS with the symptom‐to‐balloon and door‐to‐balloon times. Methods: We studied 252 patients admitted with STEMI to our institution from August 2008 to September 2009. Information regarding demographic characteristics, whether EMS was used, reperfusion procedural details and mortality rates were collected prospectively. Results: Among the recruited patients, 89 (35.3%) used the EMS (EMS group) and 163 (64.7%) did not use the EMS (non‐EMS group). In the latter group, 98 (60.1%) arrived at our institution through their own transport, 56 (34.4%) first consulted general practitioners, and 9 (5.5%) initially consulted another hospital without acute medical services. Among the 245 (out of 252, 97.2%) patients who received percutaneous coronary intervention (PCI), the EMS group was more likely to undergo primary PCI (P= 0.003) while the non‐EMS group was more likely to undergo non‐urgent PCI (P= 0.002). In patients who underwent primary PCI, the EMS group had a shorter symptom‐to‐balloon time (average difference 81.6 min, P= 0.002). The door‐to‐balloon time was similar for both groups. Conclusion: Despite the availability of a centralised EMS, 64.7% of patients with STEMI did not contact EMS at presentation. These patients were less likely to receive primary PCI and had a significantly longer symptom‐to‐balloon time.     

Reliability and Validity of Prehospital Case Finding for Depression and Cognitive Impairment

OBJECTIVES: To evaluate the test–retest reliability, the concurrent criterion validity, and the construct validity of prehospital, emergency medical service (EMS) case finding for depression and cognitive impairment in older adults.
DESIGN: Cross-sectional study.
SETTING: Prehospital EMS system and hospital emergency department.
PARTICIPANTS: EMS providers and community-dwelling older adult (aged ≥60) patients.
INTERVENTIONS: Case finding instruments for depression (Patient Health Questionnaire-2; PHQ-2) and cognitive impairment (Six-Item Screener).
MEASUREMENTS: The reliability and validity of these instruments.
RESULTS: Moderate test–retest reliability was found for prehospital application of the PHQ-2 (kappa=0.50) and Six-Item Screener (kappa=0.52), fair concurrent criterion validity for depression (kappa=0.36), and slight to fair concurrent criterion validity for cognitive impairment (kappa=0.11–0.23). Construct validity was demonstrated using the Multitrait-Multimethod Matrix.
CONCLUSION: Moderate test–retest reliability and construct validity were demonstrated for prehospital case finding by EMS providers for cognitive impairment and depression using these instruments. Slight to fair concurrent criterion validity was found, a result that methodological limitations could explain. These findings provide additional support for the concept of using EMS providers to detect older adults at risk for these conditions. Further work is needed to confirm the validity and effectiveness of prehospital screening before such programs are implemented.     

Application of symptom-based mind mapping combined with PBL teaching method in emergency trauma standardized resident training in MDT model

Explore the feasibility and effectiveness of accepting mind mapping combined with problem-based learning (PBL) teaching method in the standardized training of emergency surgery residents in the multi-disciplinary team (MDT) model of emergency trauma. Eighty-nine doctors under training who rotated in the Department of Emergency Surgery of the First Affiliated Hospital of Anhui Medical University from January 2021 to January 2022 were selected as the study subjects, and randomly divided into a group receiving mind mapping combined with PBL teaching and a group receiving traditional lecture-based learning teaching. Mini-clinical evaluation exercise (Mini-CEX), direct observation of procedural skills (DOPS), teaching adherence, and satisfaction assessments were completed at the time of discharge from the department. There were no significant differences between the observation and control group trainees in terms of gender, age, education, and entry grades. Both groups of doctors were better able to participate in their respective teaching modes and made significant progress. The participants in the observation group had significantly higher Mini-CEX, DOPS, and teaching satisfaction scores than the control group (P < .05). Under the MDT model of emergency trauma, the combination of mind mapping and PBL teaching can improve the comprehensive clinical ability of the trainees more than participating in the traditional lecture-based learning teaching, which is worth promoting and implementing in the clinical standardized training.     

The evolution of today's hospital emergency departments —Current problems and challenges

The announcement of the National Heart Attack Alert Program by the National Heart, Lung and Blood Institute in June of 1991 prompted leaders of the Florida Chapter of the American College of Cardiology to develop a statewide program to reduce the morbidity and mortality from acute myocardial infarctions within Florida. It became apparent that the success of such a program would require the prompt institution of thrombolytic agents or other revascular-ization procedures in appropriate patients. No longer could the decision regarding institution of therapy await discussion by telephone and/or the arrival at the emergency department (ED) of the patient's primary care physician or cardiologist. Efforts to establish appropriate protocols for therapy revealed that many of the 25,000 or more physicians currently staffing the 5,600 or so EDs in this country were moonlighting residents or practitioners from a variety of specialties or subspe-cialties with limited or no formal EM training. Furthermore, it was learned that there were in the entire country only about 800 postgraduate, year-one Council for Graduate Medical Education accredited training positions. There were only 21 such training positions in the entire state of Florida. The reasons for these deficiencies are discussed and a challenge to correct this person power crisis is issued, not principally to the leadership of EM, but to the entire medical profession.     

Continuation of cardiopulmonary resuscitation in a Chinese hospital after unsuccessful EMS resuscitation

Objective To evaluate the efficacy of the continuation of eardiopulmonary resuscitation （CPR） following transportation to the emergency department in a Chinese hospital after unsuccessful emergency medical services （EMS） CPR. Methods From January 2002 to December 2007, emergency records of non-traumatic patients who were transported to a tertiary teaching hospital after unsuccessful EMS CPR were reviewed. Results Eigty-five patients were included, and 13 patients （15%） accomplished restoration of spontaneous circulation in our emergency department. Resuscitative possibility reached zero at around 23 minutes. One patient was discharged with a favourable neurologic outcome. Conclusions This study shows that the continuation of CPR is not futile and may improve outcomes. The outcomes should be re-evaluated in the future when prehospital information can be combined with in-hospital information （J Geriatr Cardio12009; 6：142-146）.     

The emergency services physician assistant: results of two years' experience

The physician assistant (PA) has become an integral part of urban health care. The roles chosen are diverse and often meet the particular needs of physicians or hospitals. We have developed a unique program in emergency services that allows for training and development of PAs in two distinctly different hospital settings. These PAs perform medical-surgical liaison work bridging what, at times, can be a complex cultural gap. It is our premise that these individuals can significantly improve the quality and quantity of care rendered.