An Easily Assembled, Low-Cost Model for Lateral Canthotomy Education.

BACKGROUND: Lateral canthotomy is a vision-saving procedure. However, the low incidence of orbital compartment syndrome and the expense of simulators to practice this procedure can lead to low confidence and delays in the performance of the procedure by emergency physicians. DISCUSSION: We used a simple, inexpensive, easily assembled eye model for lateral canthotomy education at a residency program and a national conference obtaining feedback from simulation participants. Residents rated procedure laboratories that included the lateral canthotomy model as 4.9 to 5 (on a 5-point Likert scale, with 5 being the best score). National conference participants rated the model a 9 as a useful training model for practitioners on a 10-point Likert scale. CONCLUSION: This simple task trainer is practical, inexpensive, quickly assembled, and useful as a tool for practicing emergency medicine providers.

Human Factors and Simulation in Emergency Medicine.

This consensus group from the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes" held in Orlando, Florida, on May 16, 2017, focused on the use of human factors (HF) and simulation in the field of emergency medicine (EM). The HF discipline is often underutilized within EM but has significant potential in improving the interface between technologies and individuals in the field. The discussion explored the domain of HF, its benefits in medicine, how simulation can be a catalyst for HF work in EM, and how EM can collaborate with HF professionals to effect change. Implementing HF in EM through health care simulation will require a demonstration of clinical and safety outcomes, advocacy to stakeholders and administrators, and establishment of structured collaborations between HF professionals and EM, such as in this breakout group.

Consensus-Based Recommendations for an Emergency Medicine Pain Management Curriculum.

BACKGROUND: Increased prescribing of opioid pain medications has paralleled the subsequent rise of prescription medication-related overdoses and deaths. We sought to define key aspects of a pain management curriculum for emergency medicine (EM) residents that achieve the balance between adequate pain control, limiting side effects, and not contributing to the current public health opioid crisis. METHODS: We convened a symposium to discuss pain management education in EM and define the needs and objectives of an EM-specific pain management curriculum. Multiple pertinent topics were identified a priori and presented before consensus work. Subgroups then sought to define perceived gaps and needs, to set a future direction for development of a focused curriculum, and to prioritize the research needed to evaluate and measure the impact of a new curriculum. RESULTS: The group determined that an EM pain management curriculum should include education on both opioid and nonopioid analgesics as well as nonpharmacologic pain strategies. A broad survey is needed to better define current knowledge gaps and needs. To optimize the impact of any curriculum, a modular, multimodal, and primarily case-based approach linked to achieving milestones is best. Subsequent research should focus on the impact of curricular reform on learner knowledge and patient outcomes, not just prescribing changes. CONCLUSIONS: This consensus group offers a path forward to enhance the evidence, knowledge, and practice transformation needed to improve emergency analgesia.

Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: A randomized crossover trial.

BACKGROUND: Medication dosing errors remain commonplace and may result in potentially life-threatening outcomes, particularly for pediatric patients where dosing often requires weight-based calculations. Novel medication delivery systems that may reduce dosing errors resonate with national healthcare priorities. Our goal was to evaluate novel, prefilled medication syringes labeled with color-coded volumes corresponding to the weight-based dosing of the Broselow Tape, compared to conventional medication administration, in simulated prehospital pediatric resuscitation scenarios. METHODS: We performed a prospective, block-randomized, cross-over study, where 10 full-time paramedics each managed two simulated pediatric arrests in situ using either prefilled, color-coded syringes (intervention) or their own medication kits stocked with conventional ampoules (control). Each paramedic was paired with two emergency medical technicians to provide ventilations and compressions as directed. The ambulance patient compartment and the intravenous medication port were video recorded. Data were extracted from video review by blinded, independent reviewers. RESULTS: Median time to delivery of all doses for the intervention and control groups was 34 (95% CI: 28-39) seconds and 42 (95% CI: 36-51) seconds, respectively (difference=9 [95% CI: 4-14] seconds). Using the conventional method, 62 doses were administered with 24 (39%) critical dosing errors; using the prefilled, color-coded syringe method, 59 doses were administered with 0 (0%) critical dosing errors (difference=39%, 95% CI: 13-61%). CONCLUSIONS: A novel color-coded, prefilled syringe decreased time to medication administration and significantly reduced critical dosing errors by paramedics during simulated prehospital pediatric resuscitations.

Prospective analysis of an interprofessional team training program using high-fidelity simulation of contrast reactions.

OBJECTIVE: Successful management of a contrast reaction requires prompt recognition and treatment and effective team dynamics among radiologists, technologists, and nurses. A radiology department implemented a simulation program in which teams of nurses, technologists, and physicians managed simulated contrast reactions. The purpose of this study was to evaluate whether simulation improved the participants' abilities to manage a contrast reaction and work in a team during an emergency. SUBJECTS AND METHODS: Physicians, nurses, and technologists worked in inter-professional teams to manage two high-fidelity simulated adverse contrast reactions. Participants completed surveys before and after the simulation that included knowledge-based questions about the appropriate management of contrast reactions. Surveys also included questions for assessing participants' perceptions of their ability to manage adverse contrast reactions, measured with a 6-point Likert scale. Before and after comparisons were made with the McNemar test with a Bonferroni correction requiring p ≤ 0.003 for significance. For the other analyses, p ≤ 0.05 was considered significant. RESULTS: After completion of the simulation exercises, participants had significant improvement in knowledge (p < 0.001). After the simulation, participants reported significant improvement in their ability to manage an anaphylactoid reaction and their ability to work in a team (p < 0.00001). Participants requested repeat simulation exercises every 6-12 months. CONCLUSION: Simulation exercises improved the self-reported ability of radiology personnel to manage contrast reactions and work in a team during an emergency. Simulation should be incorporated into future educational initiatives to improve patient safety in radiology practices.

Color-Coded Prefilled Medication Syringes Decrease Time to Delivery and Dosing Error in Simulated Emergency Department Pediatric Resuscitations.

STUDY OBJECTIVE: The Institute of Medicine has called on the US health care system to identify and reduce medical errors. Unfortunately, medication dosing errors remain commonplace and may result in potentially life-threatening outcomes, particularly for pediatric patients when dosing requires weight-based calculations. Novel medication delivery systems that may reduce dosing errors resonate with national health care priorities. Our goal was to evaluate novel, prefilled medication syringes labeled with color-coded volumes corresponding to the weight-based dosing of the Broselow Tape, compared with conventional medication administration, in simulated pediatric emergency department (ED) resuscitation scenarios. METHODS: We performed a prospective, block-randomized, crossover study in which 10 emergency physician and nurse teams managed 2 simulated pediatric arrest scenarios in situ, using either prefilled, color-coded syringes (intervention) or conventional drug administration methods (control). The ED resuscitation room and the intravenous medication port were video recorded during the simulations. Data were extracted from video review by blinded, independent reviewers. RESULTS: Median time to delivery of all doses for the conventional and color-coded delivery groups was 47 seconds (95% confidence interval [CI] 40 to 53 seconds) and 19 seconds (95% CI 18 to 20 seconds), respectively (difference=27 seconds; 95% CI 21 to 33 seconds). With the conventional method, 118 doses were administered, with 20 critical dosing errors (17%); with the color-coded method, 123 doses were administered, with 0 critical dosing errors (difference=17%; 95% CI 4% to 30%). CONCLUSION: A novel color-coded, prefilled syringe decreased time to medication administration and significantly reduced critical dosing errors by emergency physician and nurse teams during simulated pediatric ED resuscitations.

Impact of a teaching service on emergency department throughput.

INTRODUCTION: There are 161 emergency medicine residency programs in the United States, many of which have medical students rotating through the emergency department (ED). Medical students are typically supervised by senior residents or attendings while working a regular shift. Many believe that having students see and present patients prolongs length of stay (LOS), as care can be delayed. Our institution implemented a unique method of educating medical students while in the ED with the creation of a teaching service, whose primary goal is education in the setting of clinical care. The objective of this study was to explore the effect of the teaching service on efficiency by describing LOS and number of patients seen on shifts with and without a teaching service. METHODS: This was a retrospective chart review performed over a 12-month period of visits to an urban academic ED. We collected data on all patients placed in a room between 14:00 and 19:59, as these were the hours that the teaching shift worked in the department. We categorized shifts as 1) a teaching service with students (TWS); 2) a teaching service without students (TWOS); and 3) no teaching service (NTS). LOS and median number of patients seen on days with a teaching service, both with and without students (TWS and TWOS), was compared to LOS on days without a teaching service (NTS). RESULTS: The median LOS on shifts with a dedicated teaching service without students (TWOS) was 206 minutes, while the median LOS on shifts with a teaching service with students (TWS) was 220 minutes. In comparison, the median LOS on shifts when no teaching service was present (NTS) was 202.5 minutes. The median number of patients seen on shifts with the teaching service with students (TWS) was 44, identical to the number seen on shifts when the teaching service was present without students (TWOS). When the teaching service was absent (NTS), the median number of patients seen was 40. CONCLUSION: A teaching service in the ED is a novel educational model for medical student and resident instruction that increases total ED patient throughput and has only a modest effect on increased median length of stay for patients.

Sexual assault training in emergency medicine residencies: a survey of program directors.

INTRODUCTION: There is currently no standard forensic medicine training program for emergency medicine residents. In the advent of sexual assault nurse examiner (SANE) programs aimed at improving the quality of care for sexual assault victims, it is also unclear how these programs impact emergency medicine (EM) resident forensic medicine training. The purpose of this study was to gather information on EM residency programs' training in the care of sexual assault patients and determine what impact SANE programs may have on the experience of EM resident training from the perspective of residency program directors (PDs). METHODS: This was a cross-sectional survey. The study cohort was all residency PDs from approved EM residency training programs who completed a closed-response self-administered survey electronically. RESULTS: We sent surveys to 152 PDs, and 71 responded for an overall response rate of 47%. Twenty-two PDs (31%) reported that their residency does not require procedural competency for the sexual assault exam, and 29 (41%) reported their residents are required only to observe sexual assault exam completion to demonstrate competency. Residency PDs were asked how their programs established resident requirements for sexual assault exams. Thirty-seven PDs (52%) did not know how their sexual assault exam requirement was established. CONCLUSION: More than half of residency PDs did not know how their sexual assault guidelines were established, and few were based upon recommendations from the literature. There is no clear consensus as to how PDs view the effect of SANE programs on resident competency with the sexual assault exam. This study highlights both a need for increased awareness of EM resident sexual assault education nationally and also a possible need for a training curriculum defining guidelines for EM residents performing sexual assault exams.

Fomepizole for severe disulfiram-ethanol reactions.

Ingestion of ethanol in the presence of disulfiram may cause a histamine-like reaction due to accumulation of acetaldehyde. These disulfiram-ethanol reactions (DERs) are manifested by hypotension, tachycardia, gastritis, and angioedema. Fomepizole, an inhibitor of alcohol dehydrogenase, may halt progression of this reaction by blocking ethanol metabolism to acetaldehyde. We present 2 cases of disulfiram and alcohol overdose leading to severe reactions unresponsive to fluid resuscitation and treated with a single dose of fomepizole. Case 1: A 20-year-old woman presented after ingestion of vodka and disulfiram. After 11 hours of resuscitation, she had skin flushing, lip swelling, tachycardia, and hypotension. Antihistamines, steroids, and an additional 2 L of normal saline were given without improvement. Fomepizole 15 mg/kg was given with improvement within 1.5 hours, and she was ultimately discharged with no clinical sequelae. Case 2: A 47-year-old woman presented after overdose of vodka and disulfiram. She was tachycardic and hypotensive upon presentation. After administration of 3 L of normal saline, she remained hypotensive and tachycardic. One dose of fomepizole 15 mg/kg was given. Within 1 hour following fomepizole infusion, her blood pressure and heart rate normalized, and she had no further sequelae from her ingestion. Fomepizole may be a safe and effective treatment of severe DERs. We suggest that 1 dose of fomepizole for severe DERs with hypotension unresponsive to fluid resuscitation or for angioedema unresponsive to antihistamines be administered.