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Aim: To identify specific activities associated with high cognitive load during simulated pediatric out-of-hospital cardiac arrest (POHCA) resuscitation using physiological monitoring with functional near-infrared spectroscopy (fNIRS). Methods: We recruited teams of emergency medical services (EMS) responders from fire departments located throughout the Portland, OR metropolitan area to participate in POHCA simulations. Teams consisted of both paramedics and emergency medical technicians (EMTs), with one paramedic serving as the person in charge (PIC). The PIC was outfitted with the OctaMon to collect fNIRS signals from the prefrontal cortex. Signals reported changes in oxygenated and deoxygenated hemoglobin concentrations, which were used to determine moments of increased cognitive activity. Increased cognitive activity was determined by significant increases in oxygenated hemoglobin and decreases in deoxygenated hemoglobin. Significant changes in fNIRS signals were associated with specific concurrent clinical tasks recorded by two independent researchers using video review. Results: We recorded cognitive activity of EMS providers in 18 POHCA simulations. We found that a proportion of PIC's experienced relatively high cognitive load during medication administration, defibrillation, and rhythm checks compared to other events. Conclusion: EMS providers commonly experienced increased cognitive activity during key resuscitation tasks that were related to safely coordinating team members around calculating and administering medications, defibrillation, and rhythm and pulse checks. Understanding more about activities that require high cognitive demand can inform future interventions that reduce cognitive load.
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BACKGROUND: This methodological intersection article demonstrates a method to measure cognitive load in clinical simulations. Researchers have hypothesized that high levels of cognitive load reduce performance and increase errors. This phenomenon has been studied primarily by experimental designs that measure responses to predetermined stimuli and self-reports that reduce the experience to a summative value. Our goal was to develop a method to identify clinical activities with high cognitive burden using physiologic measures. METHODS: Teams of emergency medical responders were recruited from local fire departments to participate in a scenario with a shockable pediatric out-of-hospital cardiac arrest (POHCA) patient. The scenario was standardized with the patient being resuscitated after receiving high-quality CPR and 3 defibrillations. Each team had a person in charge (PIC) who wore a functional near-infrared spectroscopy (fNIRS) device that recorded changes in oxygenated and deoxygenated hemoglobin concentration in their prefrontal cortex (PFC), which was interpreted as cognitive activity. We developed a data processing pipeline to remove nonneural noise (e.g., motion artifacts, heart rate, respiration, and blood pressure) and detect statistically significant changes in cognitive activity. Two researchers independently watched videos and coded clinical tasks corresponding to detected events. Disagreements were resolved through consensus, and results were validated by clinicians. RESULTS: We conducted 18 simulations with 122 participants. Participants arrived in teams of 4 to 7 members, including one PIC. We recorded the PIC's fNIRS signals and identified 173 events associated with increased cognitive activity. [Defibrillation] (N = 34); [medication] dosing (N = 33); and [rhythm checks] (N = 28) coincided most frequently with detected elevations in cognitive activity. [Defibrillations] had affinity with the right PFC, while [medication] dosing and [rhythm checks] had affinity with the left PFC. CONCLUSIONS: FNIRS is a promising tool for physiologically measuring cognitive load. We describe a novel approach to scan the signal for statistically significant events with no a priori assumptions of when they occur. The events corresponded to key resuscitation tasks and appeared to be specific to the type of task based on activated regions in the PFC. Identifying and understanding the clinical tasks that require high cognitive load can suggest targets for interventions to decrease cognitive load and errors in care.
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BACKGROUND: The efficacy of pre-hospital emergency services is heavily dependent on the effective communication of care providers. This effective communication occurs between providers as part of a team and also among providers interacting with family members and patients. The COVID-19 pandemic introduced a number of communication challenges to emergency care, which are primarily linked to the increased use of personal protective equipment (PPE). OBJECTIVE: We sought to analyze the impacts of the COVID-19 pandemic on emergency medical service (EMS) workers and pre-hospital care delivery. METHODS: We conducted focus groups and one-on-one interviews with fire-based EMS first responders between September 2021 and 2022. Interviews included questions about job-related stress, EMS skills, work experiences and changes during COVID-19. Interviews were recorded, independently dual coded and analyzed for themes. RESULTS: Two hundred twenty-three first responders participated in 40 focus groups and 40 lead paramedics participated in individual interviews. We found that additional use of PPE was reported to have significantly impaired efficiency and perceptions of quality of care-among EMS team members and also between EMS workers and patients. EMS personnels also experienced on-scene hostility on arrival (from both families and other agencies). Extensive use of PPE muffles voices, obscures facial expressions and can cause team members to have difficulty recognizing and communicating with one another and can be a barrier to showing empathy and connecting with patients. Creative solutions such as putting a hand on someone's shoulder, wearing name tags on suits and explaining rationale for perceived delays were mentioned as methods to transcend these barriers. The appearance of providers in heavy PPE can be unsettling and create barriers to human connection, particularly for pediatric patients. CONCLUSION: Human connection is an important element of health-care delivery and healing. These findings shed light on new skills that are needed to initiate and maintain human connection in these times of PPE use, especially full-body PPE. Awareness of the communication and empathy barriers posed by PPE is the first step to improving provider-patient interactions in pre-hospital EMS. Additionally, 'communication-friendly' adaptations of PPE equipment may be an important area for future research and development in manufacturing and the health-care industry.
