Resuscitation Leadership Training: A Simulation Curriculum for Emergency Medicine Residents.

Introduction: Throughout training, emergency medicine (EM) residents must learn to work within, and eventually lead, multidisciplinary teams in high-acuity dynamic situations. Most residents do not undergo formal resuscitation team leadership training but learn these skills through mentorship by and observation of senior physicians. We designed and implemented a formal simulation-based leadership training program for EM residents. Methods: We developed a resuscitation team leadership curriculum in which 24 junior EM residents participated in an initial simulation of a critically ill patient before undergoing a didactic presentation regarding crisis resource management (CRM) principles. Residents applied those principles in three subsequent simulations. Faculty observers evaluated each case using EM Milestones, the Ottawa Global Rating Scale (GRS), and critical actions checklists. Residents then completed surveys evaluating their own leadership and communication skills before and after the course. Results: Scores from the Ottawa GRS, critical actions checklists, and several of the EM Milestones were significantly better in the latter three cases (after completing the CRM didactics) than in the first case. After completing this curriculum, residents felt that their ability to both lead resuscitations and communicate effectively with their team improved. Discussion: Implementation of the resuscitation team leadership curriculum improved EM residents' leadership performance in critically ill patient scenarios. The curriculum also improved residents' comfort in leading and communicating with a team. Similar formal leadership development curricula, especially when combined with simulation, may enhance EM physician training. Future studies will include other multidisciplinary team members to create a more realistic and inclusive learning environment.

Accuracy of Emergency Medical Services Dispatcher and Crew Diagnosis of Stroke in Clinical Practice.

BACKGROUND: Accurate recognition of stroke symptoms by Emergency Medical Services (EMS) is necessary for timely care of acute stroke patients. We assessed the accuracy of stroke diagnosis by EMS in clinical practice in a major US city. METHODS AND RESULTS: Philadelphia Fire Department data were merged with data from a single comprehensive stroke center to identify patients diagnosed with stroke or TIA from 9/2009 to 10/2012. Sensitivity and positive predictive value (PPV) were calculated. Multivariable logistic regression identified variables associated with correct EMS diagnosis. There were 709 total cases, with 400 having a discharge diagnosis of stroke or TIA. EMS crew sensitivity was 57.5% and PPV was 69.1%. EMS crew identified 80.2% of strokes with National Institutes of Health Stroke Scale (NIHSS) ≥5 and symptom duration <6 h. In a multivariable model, correct EMS crew diagnosis was positively associated with NIHSS (NIHSS 5-9, OR 2.62, 95% CI 1.41-4.89; NIHSS ≥10, OR 4.56, 95% CI 2.29-9.09) and weakness (OR 2.28, 95% CI 1.35-3.85), and negatively associated with symptom duration >270 min (OR 0.41, 95% CI 0.25-0.68). EMS dispatchers identified 90 stroke cases that the EMS crew missed. EMS dispatcher or crew identified stroke with sensitivity of 80% and PPV of 50.9%, and EMS dispatcher or crew identified 90.5% of patients with NIHSS ≥5 and symptom duration <6 h. CONCLUSION: Prehospital diagnosis of stroke has limited sensitivity, resulting in a high proportion of missed stroke cases. Dispatchers identified many strokes that EMS crews did not. Incorporating EMS dispatcher impression into regional protocols may maximize the effectiveness of hospital destination selection and pre-notification.

Recognition of Stroke by EMS is Associated with Improvement in Emergency Department Quality Measures.

OBJECTIVE: Hospital arrival via Emergency Medical Services (EMS) and EMS prenotification are associated with faster evaluation and treatment of stroke. We sought to determine the impact of diagnostic accuracy by prehospital providers on emergency department quality measures. METHODS: A retrospective study was performed of patients presenting via EMS between September 2009 and December 2012 with a discharge diagnosis of transient ischemic attack (TIA), ischemic stroke (IS), or intracerebral hemorrhage (ICH). Hospital and EMS databases were used to determine EMS impression, prehospital and in-hospital time intervals, EMS prenotification, NIH stroke scale (NIHSS), symptom duration, and thrombolysis rate. RESULTS: 399 cases were identified: 14.5% TIA, 67.2% IS, and 18.3% ICH. EMS providers correctly recognized 57.6% of cases. Compared to cases missed by EMS, correctly recognized cases had longer median on-scene time (17 vs. 15 min, p = 0.01) but shorter transport times (12 vs. 15 min, p = 0.001). Cases correctly recognized by EMS were associated with shorter door-to-physician time (4 vs. 11 min, p < 0.001) and shorter door-to-CT time (23 vs. 48 min, p < 0.001). These findings were independent of age, NIHSS, symptom duration, and EMS prenotification. Patients with ischemic stroke correctly recognized by EMS were more likely to receive thrombolytic therapy, independent of age, NIHSS, symptom duration both with and without prenotification. CONCLUSION: Recognition of stroke by EMS providers was independently associated with faster door-to-physician time, faster door-to-CT time, and greater odds of receiving thrombolysis. Quality initiatives to improve EMS recognition of stroke have the potential to improve hospital-based quality of stroke care.

Bradycardia caused by intravenous nicardipine in an elderly patient with acute ischemic infarct.

Nicardipine is a dihydropyridine calcium-channel blocker that is frequently used in the acute treatment of hypertension in the emergency department (ED). Reflex sympathetic tachycardia is a well-described side effect of this medication. Two experimental studies and 1 anesthesia case report, however, have previously described nicardipine-induced bradycardia as a very rare side effect. We report the case of an elderly patient with an acute ischemic stroke who developed nicardipine-induced bradycardia in the ED.