Emergency medicine residents’ needs assessment for education and training using nationwide survey

Objective@#This study was conducted to identify the needs assessment for education and training of emergency medicine (EM) residents. @*Methods@#The results of a national survey of EM residents of the Korean Society of Emergency Medicine in 2019 were used. Education was one of the five categories in the survey. The preferred learning methods and their perceived importance and ability to perform in nine competencies were assessed. The Borich’s needs assessment model was used to analyze their needs. @*Results@#Among 591 EM residents, 382 responded, and 371 responses were finally analyzed. Regarding the learning methods, junior residents preferred in-hospital conferences, staff lectures, internet resources, and textbooks. Overall, medical knowledge and procedural skills were the most important, and research was less important to recognize. Medical knowledge showed the highest rank in the needs assessment in all years, and ethics and professionalism showed the lowest ranks. The needs for procedural skills were higher in junior years but lower in senior years. @*Conclusion@#These results will form the basis for the design of training programs to meet the educational needs of EM residents for each grade. Furthermore, an analysis of the educational needs should be done periodically according to the changes and demands of the times.

Innovative screening tests for COVID-19 in South Korea

Recently, the number of Corona Virus Disease 2019 (COVID-19) cases has increased remarkably in South Korea, so the triage clinics and emergency departments (ED) are expected to be overcrowded with patients with presumed infection. As of March 21st, there was a total of 8,799 confirmed cases of COVID-19 and 102 related deaths in South Korea that was one of the top countries with high incidence rates [1]. This sharp increase in infection is associated with 1) outbreaks in individual provinces, 2) deployment of rapid and aggressive screening tests, 3) dedicated healthcare staffs for virus screening tests, 4) quarantine inspection data transparency and accurate data reporting, and 5) public health lessons from previous Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks. This commentary introduces innovative screening tests that are currently used in South Korea for COVID-19, e.g., Drive-Through and Walk-Through tests, and compare the advantages and disadvantages of both methods.

How many emergency medicine residents reselect their specialty if they could?

Objective@#The 2019 Korean Emergency Medicine Residents Survey (KEMRS) is the first survey by the Korean Society of Emergency Medicine (KSEM) on the comprehensive satisfaction of their residents. Satisfaction is important not only for the personal well-being of the residents but also for patient safety. @*Methods@#A total of 622 emergency medicine residents were surveyed, using both a paper and email questionnaire from May to August of 2019. Factors related to satisfaction were analyzed. @*Results@#Of the responders, 66% said they would reapply for the emergency specialty and 51% said that they would reselect the same training hospital. The group of residents who said they would choose emergency medicine again felt that their expectations had been met and that they were comfortable with the choice of the specialty. They felt that the factors of satisfaction with their shift schedule and personal health played a more important role in their reselection of the training hospital than the workload. @*Conclusion@#The satisfaction levels of the Korean emergency residents were low. Thus, training hospitals should provide a reasonable working environment to increase their satisfaction. Also, it is important to create an environment where residents can feel rewarded and proud of the work they do.

How many emergency medicine residents reselect their specialty if they could?

Objective@#The 2019 Korean Emergency Medicine Residents Survey (KEMRS) is the first survey by the Korean Society of Emergency Medicine (KSEM) on the comprehensive satisfaction of their residents. Satisfaction is important not only for the personal well-being of the residents but also for patient safety. @*Methods@#A total of 622 emergency medicine residents were surveyed, using both a paper and email questionnaire from May to August of 2019. Factors related to satisfaction were analyzed. @*Results@#Of the responders, 66% said they would reapply for the emergency specialty and 51% said that they would reselect the same training hospital. The group of residents who said they would choose emergency medicine again felt that their expectations had been met and that they were comfortable with the choice of the specialty. They felt that the factors of satisfaction with their shift schedule and personal health played a more important role in their reselection of the training hospital than the workload. @*Conclusion@#The satisfaction levels of the Korean emergency residents were low. Thus, training hospitals should provide a reasonable working environment to increase their satisfaction. Also, it is important to create an environment where residents can feel rewarded and proud of the work they do.

Acute Care Surgery Model for Emergency Cholecystectomy

PURPOSE: Acute care surgery (ACS) models have evolved worldwide over the last decade. However, South Korea has an established trauma system and does not consider the ACS model. This study compares the management and outcome of emergency cholecystectomy in the ACS model to those of traditional on-call attending surgeon model for emergency surgery. METHODS: Retrospectively collected data for patients who underwent emergency cholecystectomy from May 2013 to January 2015 was analyzed to compare data from a traditional on-call system (OCS) and ACS. RESULTS: One hundred and twenty-four patients were enrolled in the study (62 patients ACS vs. 62 patients OCS). Hospital stay (days) (ACS=4.29±2.49 vs. OCS=4.82±4.48, p=0.46) and stay in emergency room (minutes) (ACS=213.10±113.99 vs. OCS=241.10±150.73, p=0.20) did not differ significantly between groups. Operation time (minutes) was significantly shorter in the ACS than OCS group (389.97±215.21 vs. 566.35±290.14, p<0.001). Other clinical variables (sex, open-conversion rate, whether the operation was performed at night/holiday, intensive care unit admission rate) did not differ between groups. There was no mortality and readmission. CONCLUSION: The implementation of the ACS led to shorter operation time and no increase of postoperative mortality and complication.

A Simulation Study for Quality of Chest Compression Provided by Health Personnel / 대한구급학회지

BACKGROUND: Effective chest compression may improve the return of spontaneous circulation and neurologic outcome in arrest victims. For fear of rescuer's fatigue, guidelines for cardiopulmonary resuscitation (CPR) recommended that chest compression (CC) should be switched every 2 minutes, but there is little evidence. We investigated whether health personnel could provide consistent quality of CC for 2 minutes. METHODS: We recruited prospectively health personnel working on one university hospital. On the day assigned randomly, CPR performance data was collected with use of CPR recording technology. Quality of CPR was calculated every 30 seconds interval. To identify the quality decay, we used repeated measure analysis of variance with SPSS 17.0 for analysis. RESULTS: We analyzed 8,485 CCs performed by 41 subjects. Total number of CC decayed between 90 to 120 seconds (51.6 +/- 3.3 to 50.8 +/- 3.5, p = 0.020) within recommended range. The ratio of correct depth CC decayed between 90 to 120 seconds, falling from 83.4 +/- 24.9% to 68.3 +/- 38.4% (p = 0.002). The ratio of low depth CC increased significantly over time (10.2 +/- 20.7% to 31.3 +/- 38.5%, p < 0.001). CONCLUSIONS: Health personnel may provide adequate number of CC for 2 minutes. But, the number of correct depth CC may decay between 90 to 120 seconds. Also the number of low depth CC may increase over time.

Quality and Rescuer's Fatigue with Repeated Chest Compression: A Simulation Study for In-hospital 2 Persons CPR

PURPOSE: The 2005 guidelines for cardiopulmonary resuscitation (CPR) caution that effective compression is essential (Class I) and chest compression (CC) by rescuers should be switched every 2 minutes to avoid rescuer's fatigue. It is controversial how long effective CC by a single individual can be provided. There are few reports about CPR quality, especially when rescuers perform CC for more than 10 minutes. The mean CPR period was about 30 minutes in Korea. We investigated the quality of CC and rescuer's fatigue after about 30 minutes. METHODS: From April 2009 to July 2009, health care providers (HCPs) were recruited into this study. The study simulated 2 person, in-hospital CPR. On the test day, which had been randomly assigned, each participant performed 7 CCs for about 30 minutes. The period of each CC was 2 minutes, and the period of each circulation check was 5 seconds. Participants' heart rates (HR) and visual analogue scale (VAS) scores for fatigue were obtained before and after each CC. Data for each 2 minutes CC was obtained with the use of Resusci Anne(R) with the Laerdal(R) PC skill reporting system. We used one-way repeated measures ANOVA for comparison of quality and fatigue of each CC and multiple linear regression for finding the predictors for correct CC. SPSS 17.0 was used for analysis. RESULTS: Among a total of 30 HCPs, data from 27 were analyzed. All participants were certified as a BLS provider and some were certified as BLS instructors. The rate of effective compression was 83.8+/-24.3%. Despite 2 min CC tasks were repeated alternatively for about 30 minutes, there were no differences in the number of correct CCs, depth and velocity of compression, and the number of incorrect CCs. CONCLUSION: During in-hospital CPR, HCPs may provide effective chest compressions on shifts with minimal effect of fatigue, even if they provide CC for 30 minutes.

Can Pulse Oximetry Plethysmography Waveform Amplitude in Respiratory Variations Predict fluid Responsiveness on Spontaneously Breathing Adult Shock Patients?

PURPOSE: It is difficult to predict volume responsiveness in hemodynamically unstable patients with spontaneous breathing activity. Our objective was to test whether the respiratory variations in pulse oximetry plethysmography (POP) waveform amplitude could predict fluid responsiveness to fluid resuscitation (FR) in spontaneously breathing adult shock patients. METHODS: We investigated 21 patients presenting with shock in the Emergency Room. We assessed hemodynamic status and calculated the respiratory variations in POP waveform amplitude before and after FR. Heart rate, blood pressures (MAP, SBP), maximal POP (POPmax), minimal POP (POPmin) and deltaPOP, defined as deltaPOP = (POPmax - POPmin) / ([POPmax + POPmin] / 2) were recorded. We measured hemodynamic parameters by doppler ultrasound, USCOM(R). RESULTS: Comparisons of hemodynamic parameters between before and after FR showed no significant difference in heart rate, but POP showed significant differences in changes in SBP, MAP, cardiac index, stroke volume index and respiratory variations. In response group(> or =15% in delta CI), the change in cardiac index, stroke volume index, and the respiratory variation in the POP were not significantly different. CONCLUSION: In spontaneously breathing patients with shock, we suggest that delta POP is not a reliable parameter in the prediction of fluid responsiveness.

Variations in Pulse Oximetry Plethysmographic Waveform Amplitude and Hemodynamic Assessment Induced by Passive Leg Raising in Spontaneously Breathing Adult Volunteers / 대한구급학회지

BACKGROUND: In hemodynamically unstable patients with spontaneous breathing activity, predicting volume responsivenss is a difficult challenge. Our objective was to test whether the respiratory changes in pulse oxymetry plethysmographic waveform amplitude (POP) and in stroke volume (deltaSV) could predict fluid responsiveness to passive leg raising (PLR) in normal volunteers. METHODS: We investigated 25 normal volunteers. We assessed hemodynamic status (HR, SBP, MAP, CI and SVI) and calculated the respiratory variation in pulse oximetry plethysmographic waveform amplitude at supine and after PLR. We attached a pulse oximeter of 25 spontaneously breathing volunteers as several time points: after 1 min and 5 min in supine position and during PLR at 60degrees. Heart rate, non-invasive blood pressures (mean arterial pressure, systolic blood pressure), maximal POP (POPmax), minimal POP (POPmin) and deltaPOP defined as (POPmax-POPmin)/[(POPmax+POPmin)/2] were recorded using monitor. RESULTS: Comparing to supine and PLR, systolic blood pressure and mean arterial pressure were not different, but the change in cardiac index, stroke volume and respiratory variation in POP were significant different. In response group (> or =10% in deltaCI), the change in cardiac index, stroke volume and respiratory variation in POP were significant greater. CONCLUSION: PLR induces a significant decrement of variation in POP amplitude among spontaneouely breathing volunteers. We suppose that the changes in stroke volume and the respiratory variation in pulse oximetry plethysmographic waveform amplitude induced by PLR predict fluid responsiveness in spontaneous breathing patients.

Factors of Cardiopulmonary Resuscitation Outcome for In-hospital Adult Patients / 대한구급학회지

BACKGROUND: The purpose of this study was to evaluate the factors of cardiopulmonary resuscitation (CPR) outcome for in-hospital adult patients, acquiring data with standardized reporting guideline of in-hospital cardiopulmonary resuscitation in Korea. METHODS: All adult cardiac arrest patients from July 2004 to December 2006 in this general hospital were included. Their clinical spectrums were reviewed retrospectively using Utstein-style based template. RESULTS: For the study time period, one hundred and forty-two patients underwent cardiac arrest in this hospital. 136 patients were performed CPR. Return of spontaneous circulation (ROSC) occurred in 42 cases, and 15 patients were survived to hospital discharge. A shorter CPR time and a lower Simplified Acute Physiology Score II (SAPS II) were significant for survivor to hospital discharge (p<0.01). Sex, age, and location in cardiac arrest were not attributed to survival to hospital discharge. CONCLUSIONS: In-hospital CPR patients, the high rate of ROSC and survival to hospital discharge were associated to the cause of arrest, shorter time of CPR, and lesser severity of disease (SAPS II). This result can be a great implication of survivor from CPR in-hospital adult patients in Korea. Further evaluation with consistent data acquisition of CPR using Utstein-style would contribute to improve CPR practice and outcome.

Comparison of Impedance Cardiography with Thermodilution of Hemodynamic Parameters in Critically Ill Patients / 대한구급학회지

BACKGROUND: To evaluate the feasibility of noninvasive hemodynamic monitoring (impedance cardiography, ICG) in critically ill patients, we compared this technique with simultaneous invasive monitoring with a pulmonary artery thermodilution catheter. METHODS: A prospective observational study was done comparing invasive monitoring and noninvasive monitoring in 12 critically ill patients. The cardiac output (CO), the stroke volume (SV) and the systemic vascular resistance (SVR) measured by using a standard thermodilution pulmonary artery catheter technique were compared with the corresponding measurements simultaneously using an ICG. RESULTS: The value of CO, SV and SVR measured by ICG were closely correlated to those by the thermodilution methods [r: 0.659 (p<0.01), 0.536 (p<0.01), 0.738 (p<0.01)]. CONCLUSIONS: ICG can provide hemodynamic information previously available only by invasive monitoring with a thermodilution catheter.

Diagnostic Value of Ultrasonography for the Assessment of Rib Fractures

PURPOSE: Rib fractures are the most common injuries resulting from blunt chest trauma. The sensitivity of conventional chest radiography (chest PA, rib series) in showing a rib fracture is limited, particularly in those involving the cartilage part of the rib. We investigated the possible rib fractures. We used ultrasonography (US) to investigate possible rib fractures in patients with minor blunt chest trauma who showed no evidence of a rib fracture on the conventional chest radiography. METHODS: A total of 96 patients with minor blunt chest trauma and showing no evidence of a rib fracture on the conventional chest radiography were examined with US performed with a 7.5-MHz linear transducer. RESULTS: A total of 44(45.8%) patients showed a rib fracture whereas 52(54.2%) patients had no evidence of a rib fracture. Fracture of the rib with displacement 24 patients was the most common finding. CONCLUSIONS: Rib US is a useful imaging method in showing rib fractures overlooked on chest X-rays in cases of minor blunt chest trauma. Compared with conventional chest radiography, rib US takes a shorter time and is not difficult. Additionally, lesions combined with rib fractures and costal cartilage fractures are diagnosed more easily when using rib US.

Short-Term Revisits to Emergency Medical Center

PURPOSE: More than a few patients revisit Emergency Departments (EDs) with the same complaint. It is generally assumed that a revisit within a short period happens due to an inadequate evaluation during the previous visit, which creates a quality problem in emergency care. The purpose of this study is to analyze patient's revisiting the ED within 48 hours after being discharged and to use this information as a tool for quality assurance in the ED. METHODS: We carried out a chart review of patients who have revisited the ED within 48 hours between March 1, 2000 and February 28, 2002. We divided the patients into three groups according to their age. Disease variables were analyzed according to the age groups and admission rates. RESULTS: A total of 78,182 patients visited the ED during the period. Of these, 66,974 patients were discharged from the ED and the others were admitted. Of these discharged, 1,012 patients revisited the ED with the same complaints within 48 hours. The common disease or complaint of the short-term revisiting patients in order were acute abdomen, acute pharyngotonsilitis, ureter stones, respiratory problems, etc. Admissions of revisiting patients were due to acute abdomen, acute gastroenteritis, acute appendicitis, intussucception, panperitonitis, ileus, etc. There were significantly different admission rates according to initial symptoms, diseases and the age group of the revisiting patient. CONCLUSION: For quality improvement of emergency care, we need to standardize a management protocol, and the guidance for patient care provided in this paper might be recommended. A short -stay unit in the ED may be useful in some cases.

Survey on Emergency Medicine Specialists in Korea : Working Patterns and Level of Satisfaction

PURPOSE: This research was to investigate and analyze the working conditions and level of satisfaction, to suggest ideal working conditions for emergency medicine specialists, and to propose a future direction for the advancement of emergency medicine. METHODS: Among the 185 doctors who were EM board-certified from 1996 to 2000 in Korea, this survey was sent to 129 emergency medicine specialists; to those 57 answered the questionnaire. The questionnaire was made up of 17 items in the form of short answeres and descriptions. The analysis was done using the SPSS WIN program. RESULTS: From the survey, the level of dissatisfaction was found to be higher than the level of satisfaction and the most prominent cause was the working conditions, including night duty. The most ideal working pattern sought after was an 8-hour workshift and this result did not vary with the specialists the position in the hospital. At present, night duty is not performed by most specialists, but rather extended weekend duty is. The number of specialists employed at most emergency medical centers is under 3 (81.7%). As the ideal number of specialists (more than 4 in 89.5%) is not being reached, 24-hour stationing of a specialist at an emergency medical center is not being achieved. CONCLUSION: This survey was done in order to establish the proper working conditions and a base for improving emergency medicine itself by investigating and studying the present working conditions of emergency medicine specialists, their complaints, and their proposals for advancing of emergency medicine.

The Influences of Moderate Hypothermia on the Brain Neurotransmitter Content in the Gerbil Global Ischemic: Reperfusion Model

PURPOSE: Hypothermia induces tolerance to ischemic brain injury and has protective effects. The role of catecholamine and indole amine in ischemic brain injury has not been well documented. To investigate the relationships between hypothermia and catecholamines in ischemia-induced brain damage, we performed a quantitative measurements of the catecholamines in each brain region after a periods of ischemia and ischemia reperfusion. METHODS: By using the Gerbil global ischemic reperfusion model, we divided the experimental group into control, ischemia (10 minute), ischemia with hypothermia, ischemia reperfusion, and ischemia reperfusion with hypothermia groups. After periods of ischemia and ischemia reperfusion with or without hypothermia, the amine concentrations in five brain regions were measured using high performance liquid chromatography (HPLC). RESULTS: The norepinephrine (NE) content in the hippocampus was increased in the ischemia group and the ischemia reperfusion with hypothermia group, but diminished in the ischemia with hypothermia group and the ischemia reperfusion group (p<0.05). The dopamine content was decreased in the hippocampus in the ischemia with hypothermia group and was increased in the ischemia reperfusion with hypothermia group. However, the striatal dopamine content was increased in the ischemia with hypothermia. The contents of both 5-HT and 5-HIAA in the striatum of both referfusion groups were changed significantly. The contents of the other neurotansmitters were changed markedly, but the changes had no statistical significance. CONCLUSION: This study indicates that ischemia and hypothermia have great influences on amine contents of the brains, and suggests that much researches is required to elucidate the effects of hypothermia on the neurotransmitter content in ischemic-reperfusion brain injury.

A Case of Severe Hypothermia with Cerebral Hemorrhage

Hypothermia is not an uncommon condition that emergency physicians meet in their emergency department services. Most cases involve mild hypothermia and are rewarmed well without any complication or sequelae. Hypothermia is well known to be correlated with drug intoxication, such as with alcohol. Since alcohol adds to the suppressive effect on central nervous system due to hypothermia, most intoxicated patients are so deeply drunk that they look comatous. We report the case of a 41-year old male drunk and semi-comatous and who had been left in his car for more than 12 hours on a freezing cold night. He arrived at our emergency department with a body temperature of 27.3degrees C. The patient was warmed with active rewarming, and during the procedure, the patient appeared markedly hypertensive, instead of showing rewarming shock. After initial stabilization the patient was taken for a cerebral CT scan and was found to have a large amount of intracranial hemorrhage. He was treated conservatively in the intensive care unit and was discharged as a hopeless case.

Effect of Local Anesthesia for Nasogastric Tube Placement

PURPOSE: This study was conducted to assess the effect of sprayed 10% xylocaine as a local anesthesia in reducing the pain associated with nasogastric tube(NGT) placement METHOD: This was a prospective, randomized, case-controlled trial conducted in the emergency department of a university teaching hopital. Study participants were alert patients requiring NGT placement for diagnostic or therapeutic purposes. Patients having NGT placement were randomized to receive either a 10% xylocaine solution or nothing sprayed in the nasopharynx and oropharynx. After 5 minutes, the distal 5 cm of the NGT were lubricated with a liberal amount of sterile, water-soluble, and non-anesthesient jelly before placement. After each procedure, the patient recorded assessment of subjective pain on a 100-mm visual analog scale(VAS). RESULT: A total of 71 patients were evaluated in the study with 32 in the case group and 39 in the control group. The mean VAS value of the case group was 38.8 mm(95% confidence interval[CI] 2.4 to 51.3); that of control group was 63.31 mm. The mean difference between groups was 24.40 mm(95% CI, 26.9 to 75.9). A statistically significant difference was achieved between the case and the control groups(p<0.01). CONCLUSION: Sprayed nasopharyngeal and oropharyngeal 10% xylocaine results in a statistically significant reduction in pain during NGT placement.

Ischemia-responsive Protein(irp94) Gene Expression in a Neuronal Cell Culture Model of Ischemia

BACKGROUND: The ischemia responsive protein 94 kDa(irp94) gene belongs to the heat shock protein 110 family and was isolated in 1999 from rat brain by transiently induced forebrain ischemia. The PC12 cell is the pheochromocytoma cell line of rat, which is differentiated to a sympathetic neuron-like cell by the stimulation of a nerve growth factor. This study is to determine whether irp94 is expressed when an ischemia-like condition is induced by ATP depletion in cultured PC12 cells in vitro. METHODS: PC12 cells were maintained as monolayer cultures in RPMI-1640 medium(Sigma) supplemented with 10% horse serum, 5% fetal bovine serum, 5 mg/ml transferrin, and 1 mg/ml insulin in a humidified 5% CO2 incubator at 37degrees C. The ATP depleting agent antimycin A was added at concentrations of 1, 2.5, and 5 microM to simulate ischemia, and 10 microgram/ml of tunicamycin, which is expected to express heat shock protein maximally, was used as a positive control. The cells were harvested after a 60-minute incubation, and the total RNA was extracted. The reverse transcription polymerase chain reaction(RT-PCR) was performed to use 501 bp irp94 cDNA as a molecular probe, and the expression of irp94 mRNA was analyzed by northern blotting. RESULTS: The irp94 mRNA expression was enhanced, compared to the negative control group, as the concentration of antimycin A was increased. CONCLUSION: This study suggests that irp94 mRNA expression is enhanced as the severity of ischemia is increased. Thus, it is possible to investigate the mechanism of ischemic neuronal injury indirectly by using this in-vitro model of neuronal ischemia.

Neuroprotective Effects of Intraischemic(1 hour) Moderate Hypothermia in Gerbil Brain Global Ischemic Model

BACKGROUND: In animal models of cerebral ischemic-reperfusion has been shown to have a beneficial effect. The object of this study is to compare the effect of pathologic findings between normotheimic and moderate hypothermic group. METHODS: We investigated the effect of moderate hypothermia induced 1 hour after transient(10 min) both carotid artery occlusion on the extent of ischemic-reperfusion cell damage in Mongolian Gerbil model. The terminal deoxyribonucleotidyl transferase (TdT) -mediated biotin-16-dUTP nick-end labelling(TUNEL staning) are used to detect apoptosis. RESULTS: 1. We suggest that Core body temperature is down to moderate hypothermia(30-32degrees C) beyond 10 minite by selective bain cooling method in Mongolian Gerbil model. 2. By light microscopy, ischemic-reperfusion damage were detected in the hippocampal CA1 pyramidal layer on the 3 day after transient ischemic insult, which showed chrosomal condensation and cytoplasmic eosinophilia. Ischemic-reperfusion cells were increased in the CA1 region on the 5 day. Apoptotic cells of the CA1 neurons seen by TUNEL staining than ischemic neurons seen by Hematoxylin-eosin staining were investigate 3 and 5 days after ischemic-reperfusion insult. CONCLUSION: We suggest that is not neuroprotective effects of Intraischemic(1 hour) moderate hypothermia in Gerbil brain global ischemic-reperfusion model.

An analysis of trauma patients by inury severity score and trauma score

No abstract available.