Fear Not: Utilizing Simulation for Medical Malpractice Education.

INTRODUCTION: Medical malpractice payouts across specialties totaled over $4.03 billion USD in 2019. It is estimated that over 72% of Emergency Medicine (EM) physicians will be involved in a medical malpractice lawsuit by age 55. The majority of EM residencies do not include adequate education on medicolegal risk mitigation and litigation. The purpose of the study is implementation of an innovative interprofessional simulation to target this education gap. METHODS: An anonymous pre- and post-survey was distributed to participating EM providers electronically. The surveys evaluated baseline medicolegal knowledge, self-rated deposition comfort and concern regarding malpractice litigation. The simulation event involved an interactive lecture on basic tenets of medical malpractice and state legal statutes from medicolegal experts. Resident physician volunteers acted as defendant physicians during simulated depositions using a redacted, closed malpractice case. RESULTS: Eighty EM providers attended the event over two days. All attendees completed the pre-survey (80/80), and 66.3% (53/80) completed the post-survey. The majority incorrectly answered 4 of 5 medicolegal questions. The mean comfort level regarding being deposed is 1.53 ± 0.94 on a 1-5 Likert scale (extremely uncomfortable to extremely comfortable); the mean level of concern/fear of malpractice litigation is 3.38 ± 0.95 on a 1-5 Likert scale (not at all to extremely concerned). There was a statistically significant increase in deposition comfort level post-event (1.83, P < .01). CONCLUSION: The majority of EM physicians are inexperienced and concerned regarding litigation. After participating in an educational event and observing a simulated deposition, physicians reported an increased comfort level regarding being deposed in the future.

Impact of Sports Medicine and Orthopedic Surgery Rotations on Musculoskeletal Knowledge in Residency: An Update and Longitudinal Study.

Introduction Musculoskeletal (MSK) complaints and injuries account for a significant percentage of presenting chief complaints to the emergency department in the United States (US). Despite the prevalence of disease and economic impact on the US healthcare system, there is a documented deficiency in MSK education at all training and practicing levels in the US medical system. The purpose of this study is to determine MSK knowledge acquisition after an orthopedic or primary care sports medicine (PCSM) rotation in three emergency medicine (EM) residency programs at a single institution. Methods A total of 115 EM post-graduate year 1 (PGY-1) residents participated in and completed this study over five academic years. Based on existing residency program curricula, the participants were categorized into two groups. One group completed a traditional four-week Orthopedic Surgery rotation and the other group completed a four-week Sports Medicine rotation. The validated written Freedman and Bernstein MSK examination (FB-MSK) was administered to all participants at the start of residency and at completion of their rotation. Fifty-nine of the participants participated in a longitudinal secondary study over five academic years. The FB-MSK was offered to all participants every year following the completion of their rotation during their residency. Results Post-rotation scores improved regardless of which group the resident belonged to. The orthopedic group improved an average of 3.11 points (p = <0.0001, CI 2.39 to 3.82) and the average improvement in the PCSM group was 3.97 points (p = <0.0001, CI 2.81 to 5.83). The post-rotation scores were similar regardless of the group (p = 0.4287, CI -0.73 to 1.70). The amount of improvement in scores between the two groups was not statistically significant (p = 0.209, CI -0.49 to 2.21). Of the longitudinal participants, PGY-3+ significantly scored higher than PGY-1 (p = 0.0325, 95% CI 0.165 to 3.658). Conclusion Regardless of rotation type, MSK knowledge acquisition appears to significantly improve. EM senior residents demonstrate significant MSK knowledge acquisition during residency. Further studies on a multi-institutional level are needed to account for MSK curriculum variability in residency programs.

Impact of Sports Medicine and Orthopedic Surgery Rotations on Musculoskeletal Knowledge in Residency.

Introduction Musculoskeletal (MSK) complaints and injuries comprise 18.7% of emergency department visits. However, only 61% of emergency physicians (EP) pass a validated written Freedman and Bernstein MSK examination (FB-MSK). Educational interventions such as a primary care sports medicine (PCSM) rotation aid in MSK residency education. This study utilizes a validated MSK examination to evaluate and compare MSK knowledge acquisition following a traditional orthopedic rotation and a PCSM rotation. Methods Forty-nine interns were recruited to participate in this study over two academic years. The FB-MSK was administered to all participants at the start of residency. Participants were divided into two groups based on their residency sites; one group completed a traditional four-week orthopedic surgery rotation and the second group completed a four-week PCSM rotation. Forty-six of the forty-nine participants were administered the FB-MSK after completion of their rotations. Results Individual post-rotation scores significantly improved regardless of rotation (mean difference 2.78, p<0.001; 95% CI 2.05-3.52). The orthopedic surgery group significantly improved (mean difference 2.84, p<0.001; 95% CI 1.93-3.73) and the PCSM group significantly improved (mean difference 2.64, p=0.002; 95% CI 1.23-4.07). There was no significant difference in pre-rotation scores between the two groups (p=0.86; 95% CI -2.13 to 1.79). There was no significant difference in post-rotation scores between the two groups (p=0.66; 95% CI -1.98 to 1.26). There was no significant difference in mean score improvement between the two groups (p=0.81; 95% CI -1.33 to 1.69). Conclusion This study demonstrates significant MSK knowledge acquisition and no difference in the level of knowledge acquisition after completion of either traditional orthopedic surgery or PCSM residency rotation.

Advanced closed-loop communication training: the blindfolded resuscitation.

Closed-loop communication (CLC) improves task efficiency and decreases medical errors; however, limited literature on strategies to improve real-time use exist. The primary objective was whether blindfolding a resuscitation leader was effective to improve crisis resource management (CRM) skills, as measured by increased frequency of CLC. Secondary objectives included whether blindfolding affected overall CRM performance or perceived task load. Participants included emergency medicine (EM) or EM/paediatric dual resident physicians. Participants completed presurveys, were block randomised into intervention (blindfolded) or control groups, lead both adult and paediatric resuscitations and completed postsurveys before debriefing. Video recordings of the simulations were reviewed by simulation fellowship-trained EM physicians and rated using the Ottawa CRM Global Rating Scale (GRS). Frequency of CLC was assessed by one rater via video review. Summary statistics were performed. Intraclass correlation coefficient was calculated. Data were analysed using R program for analysis of variance and regression analysis. There were no significant differences between intervention and control groups in any Ottawa CRM GRS category. Postgraduate year (PGY) significantly impacts all Ottawa GRS categories. Frequency of CLC use significantly increased in the blindfolded group (31.7, 95% CI 29.34 to 34.1) vs the non-blindfolded group (24.6, 95% CI 21.5 to 27.7). Participant's self-rated perceived NASA Task Load Index scores demonstrated no difference between intervention and control groups via a Wilcoxon rank sum test. Blindfolding the resuscitation leader significantly increases frequency of CLC. The blindfold code training exercise is an advanced technique that may increase the use of CLC.

Evaluation of an Innovative Bleeding Cricothyrotomy Model.

Objectives Emergency medicine (EM) residents are required to perform a cricothyrotomy during training as per the Accreditation Council for Graduate Medical Education (ACGME) guidelines. Cricothyrotomy is a rare procedure, comprising 0.45% of emergency department airway management procedures. Procedural competence in utilizing a realistic trainer is of utmost importance. We have developed a cricothyrotomy trainer using a fused deposition modeling (FDM) three-dimensional (3D) printer and innovative bleeding tissue to enhance fidelity. We aim to evaluate the trainer's realism. Methods Implementation occurred during a difficult airway educational lab for EM residents in April 2018. Participants completed anonymous written surveys after performing a cricothyrotomy on the trainer. The survey evaluated the realism of the trainer and compared it to other available models by utilizing five-point visual analog scales (VAS). The participants rated their comfort level in performing the procedure pre- and post-educational lab on a five-point VAS. Demographic data included postgraduate year, prior clinical cricothyrotomy experience as a primary operator versus as an assistant, and previous trainer experience. The survey included open-response suggestions for trainer improvement.  Results Forty-three EM residents completed the survey (82.7%, 43/52). The mean realism rating of the trainer was 3.81 (95% CI = 3.54-4.1). The participants reported previous training on cadaver (62.8%, 27/43), porcine (46.5%, 20/43), and manikin (67.4%, 29/43) models prior to using this trainer. The bleeding cricothyrotomy trainer was rated higher than other models (4.45, 95% CI = 4.28-4.63). Participants noted improved comfort with performing the cricothyrotomy after the educational lab (average improvement of 1.23±0.75). Participants specifically commented on the realism of the bleeding and skin texture; however, they also recommended a reduction in the size of the cricothyroid membrane space.  Conclusion The innovative bleeding cricothyrotomy trainer has greater fidelity and reported superiority when compared to other commonly used nonbleeding models. This trainer provides a more advanced platform to teach an infrequent yet critical procedural skill to emergency medicine residents.

Differences in the region- and depth-dependent microstructural organization in normal versus glaucomatous human posterior sclerae.

PURPOSE: This study quantitatively investigated differences in the regional- and depth-dependent human posterior scleral microstructure in glaucomatous (G) and nonglaucomatous (NG) donors. METHODS: Twenty-five posterior poles from six G and seven NG donors were analyzed using small angle light scattering (SALS) to investigate the organization of scleral fibers around the optic nerve head. Eccentricity (Ecc), fiber splay (FS), and percent equatorial fibers (PEF) were quantified. RESULTS: Regional statistically significant differences between G and NG groups existed in Ecc (P < 0.0001), FS (P < 0.005), and PEF (P < 0.005). Distinct and substantial variation through the depth occurred in all three end points. Region-specific differences in Ecc existed at the episcleral surface; however, by 40% into the depth, all regions converged to a similar value. Fiber splay increased in all regions by an average of 0.14 from the episcleral surface to the intraocular surface. The percentage of equatorial fibers decreased universally through the depth from approximately 61% to 33%. Generally, the inferior and superior regions had a lower Ecc and PEF compared to the nasal and temporal regions. CONCLUSIONS: Region and depth of the posterior sclera are important factors that should be included when comparing scleral microstructure of G and NG tissue in experimental and computational work. The dramatic changes in the depth of the sclera may represent baseline properties that affect predisposition to primary open angle glaucoma (POAG), and necessitate that further research include depth as a factor in assessing how observed structural differences contribute to or are a result of POAG.