[Emergencies-Infinite worlds? : Extended reality as a medium in the education, continuing and advanced training in emergency medicine]. / Der Notfall ­ unendliche Welten? : "Extended reality" als Medium in der notfallmedizinischen Aus­, Fort- und Weiterbildung.

BACKGROUND: Simulation training is indispensable in emergency medicine, especially for enhancing patient safety. Methods and technologies used include a wide spectrum ranging from simple skill trainers to complex full-scale simulated environments integrating standardized patient actors. Limitations include the simulation of dynamic changes of clinical symptoms, the depiction of emotions and patient movements as well as complex environments, such as lively traffic. Extended reality (XR) holds the potential to overcome these limitations. METHODS/AIMS: Starting with the technological basis and the didactic considerations in the field of XR, the paper reflects the potentials and limitations of this new technology in the domain of medical simulation training. Further focus is put on the integration of XR into existing training curricula. RESULTS: The XR covers various technologies, ranging from PC-based applications that are similar to conventional computer games, over virtual realities enabling spatially freely navigable 3­dimensional simulation (using closed 3D glasses: head mounted displays, HMD), to mixed-reality applications that combine virtual elements and real physical objects; however, technology alone does not stimulate learning. As with other simulation methods, it is crucial with XR to implement learning objectives, methods and technologies in a suitable teaching-learning arrangement and to familiarize teachers and students with the new technology. Evidence in the literature with respect to learning success is limited by the heterogeneity of technologies, target groups, teaching-learning arrangements and learning outcomes. Overall, significant increases can be shown for the intrinsic motivation of learners, and for high emotional participation (measured as perceived presence in the virtual environment). DISCUSSION: Technological developments and the increasing use of digital media in emergency medical education and training favor the leap from XR-based pure demonstration projects to educational practice. Decisive for the educational success are the clear orientation towards concrete learning goals and a thorough familiarization with the new technology. CONCLUSION: Simulation training based on XR expands the spectrum of existing simulation methods to integrate new dimensions of learning objectives. Further research on the effectiveness of this method is needed.

[Learning with digital media in emergency medicine-a path through the jungle of possibilities]. / Lernen mit digitalen Medien in der Notfallmedizin ­ ein Pfad durch den Dschungel der Möglichkeiten.

Background: Digital media, such as podcasts, wikis, ePortfolios, and extended reality applications, provide excellent learning opportunities with a high degree of connectivity and flexibility for learners, as well as for learning facilitators. This not only enables location-independent and pandemic-resilient learning, but also a high degree of autonomy for the learners. The megatrend of digitalization opens up many possibilities, but there are also stumbling blocks and limitations. Objectives: This article is intended to provide readers in the emergency medicine/rescue field with an overview, various aspects to consider, and awareness of stumbling blocks. However, a balancing act between didactics and medicine as well as the heterogeneous group of addressees is necessary. Methods: By means of a narrative review, an assessment of digital media is made and subjected to an evaluation from the perspective of educational practice. Conclusion: Learning is not only changing due to new learning technologies, but also due to the growing importance of informal learning, the increasing significance of the ability to quickly access high-quality knowledge, faster-changing professional biographies, and the use of digital universal tools. Thus, in the jungle of possibilities, an estimation of scientific quality criteria is often difficult and a differentiated consideration is necessary. Basically, the question of appropriate methods must be asked and it must be critically questioned whether the learning/competency objectives can be achieved with the planned digitalized media. Digital media cannot and should not replace practical training in the workplace.

An Immersive Multi-User Virtual Reality for Emergency Simulation Training: Usability Study.

BACKGROUND: Virtual reality (VR) is increasingly used as simulation technology in emergency medicine education and training, in particular for training nontechnical skills. Experimental studies comparing teaching and learning in VR with traditional training media often demonstrate the equivalence or even superiority regarding particular variables of learning or training effectiveness. OBJECTIVE: In the EPICSAVE (Enhanced Paramedic Vocational Training with Serious Games and Virtual Environments) project, a highly immersive room-scaled multi-user 3-dimensional VR simulation environment was developed. In this feasibility study, we wanted to gain initial insights into the training effectiveness and media use factors influencing learning and training in VR. METHODS: The virtual emergency scenario was anaphylaxis grade III with shock, swelling of the upper and lower respiratory tract, as well as skin symptoms in a 5-year-old girl (virtual patient) visiting an indoor family amusement park with her grandfather (virtual agent). A cross-sectional, one-group pretest and posttest design was used to evaluate the training effectiveness and quality of the training execution. The sample included 18 active emergency physicians. RESULTS: The 18 participants rated the VR simulation training positive in terms of training effectiveness and quality of the training execution. A strong, significant correlation (r=.53, P=.01) between experiencing presence and assessing training effectiveness was observed. Perceived limitations in usability and a relatively high extraneous cognitive load reduced this positive effect. CONCLUSIONS: The training within the virtual simulation environment was rated as an effective educational approach. Specific media use factors appear to modulate training effectiveness (ie, improvement through "experience of presence" or reduction through perceived limitations in usability). These factors should be specific targets in the further development of this VR simulation training.

Outcome of out-of-hospital cardiac arrest after fibrinolysis with reteplase in comparison to the return of spontaneous circulation after cardiac arrest score in a geographic region without emergency coronary intervention.

Coronary occlusion and pulmonary embolism are responsible for the majority of cases of out-of-hospital cardiac arrest (OHCA). Despite previous favourable results of pre-hospital fibrinolysis in cases of OHCA, the benefit could not be confirmed in a large controlled study using the fibrinolytic tenecteplase. For reteplase (r-PA), there are hardly any data regarding pre-hospital fibrinolysis during ongoing resuscitation. The present study reported results using r-PA therapy in a German physician-supported Emergency Medical Services system. The data of OHCA patients who received pre-hospital fibrinolytic treatment with r-PA after an individual risk/benefit assessment were retrospectively analysed. To assess the effectiveness of this approach, the rate of patients with a return of spontaneous circulation (ROSC) was compared with the corresponding figure that was calculated with the help of the RACA (ROSC after cardiac arrest) score. The RACA algorithm predicts the probability of ROSC based on data from the German Resuscitation Registry. Further outcome data comprised hospital discharge rate and neurologic status at discharge. From 2001 to 2009, 43 patients (mean age, 58.5 years; 65.1% male; 58.1% ventricular fibrillation) received r-PA. Of these, 20 patients (46.5%) achieved ROSC, compared to a probability of 49.8% according to the RACA score (P=0.58). A total of 8 patients (18.6%) were discharged alive, including 5 (11.2%) with a good neurological outcome. For the analysed small patient collective, pre-hospital r-PA did not offer any benefits with regard to the ROSC rate. Further analyses of larger patient numbers on a nationwide registry basis are recommended.

The "first digit law" - A hypothesis on its possible impact on medicine and development aid.

The "first digit law" or "Benford's law" is a mathematical distribution discovered by Simon Newcomb and Frank Benford. It states, that the probability of the leading number d (d∈{1,…,9}) in many natural datasets follows: P (d)=log10 (d+1)-log10 (d)=log10 (1+1/d). It was successfully used through tax authorities and "forensic accounting" in order to detect fraud and other irregularities. Benfords law was almost neglected for its use outside financial accounting. The planning for health care systems in developing countries is extremely dependant on good, valid data. Whether you plan the catchment area for the future district hospitals, the number of health posts, the staff establishment for the central hospital or the drug budget in the Ministry. The "first digit law" can be used in medicine, public health, physiology and development aid to unmask questionable data, to discover unexpected challenges, difficulties in the data collection process, loss through corruption and criminal fraud. Our hypothesis suggests, that the "first digit law" is a cost effective tool, which is easy to use for most people in the medical profession, which does not really needs complicated statistical software and can be used on the spot, even in the resource restricted conditions of developing countries. Several preconditions (like the size of the data set and its reach over more than two dimensions) have to be fulfilled, but then Benfords law can be used by any clinician, physiologist, public health specialist or aid consultant without difficulties and without deeper statistical knowledge in the four steps, we suggest in this article. The consequences will be different depending on the level (local regional, national, continental, international) on which you will use the law. All levels will be enabled to get insight into the validity of the data-challenges for the other levels without the help of trained statisticians or accountants. We believe that the "first digit law" is a vastly underestimated and neglected, but extremely useful tool for the identification of unexpected challenges, supervision and control in various parts of medicine and public health for almost all aspects of development aid.

Prehospital CPAP Therapy by Emergency Physicians in Patients with Acute Respiratory Failure due to Acute Cardiogenic Pulmonary Edema or Acutely Exacerbated COPD.

BACKGROUND: Acute respiratory failure is a frequent cause of emergency medical missions. Continuous positive airway pressure (CPAP) therapy could be particularly beneficial, avoiding risks associated with intubation and invasive ventilation. Hardly any data exist from Germany on this matter. PATIENTS AND METHODS: CPAP therapy with the Boussignac system as additional measure was introduced in cases of acute cardiogenic pulmonary edema (ACPE) or decompensated chronic obstructive pulmonary disease (COPD) in a physician-supported emergency medical services system (EMS). RESULTS: A total of 57 patients, 35 with ACPE and 22 with COPD, received CPAP. Oxygen saturation improved from 81.6% to 94.8%, and respiration rate from 26.9/min to 18.9/min (p<0.001). Seven patients (12.2%) needed secondary intubation [COPD: one patient; ACPE: six patients, including three with acute coronary syndrome (ACS)]. CONCLUSION: In physician-supported EMS, CPAP using the Boussignac system is an effective additional measure for ACPE or COPD. For causal ACS, the risk of therapy failure increases.

Pediatric trauma care with computed tomography--criteria for CT scanning.

Trauma centers, trauma management concepts, as well as integration of whole-body computed tomography (CT) reduced mortality significantly. The accuracy of a trauma care algorithm with emergency CT in children was evaluated. Data of 71 children with emergency CT were recorded retrospectively. In addition to epidemiological data admission date, kind of CT scan, mechanism of injury, missed diagnoses, injury severity score (ISS), admission to and time on intensive care unit (ICU), and time of hospitalization were observed. The algorithm for CT scanning was based on mechanism of injury, pattern of injury, and altered vital signs. Sixty-nine percent of the children reached the ER during on-call service hours. A percentage of 32.4 received a whole-body scan and 67.6 % a cranial scan. The mean ER ISS was 9.9 points (1-57). Children have different trauma mechanisms compared to adults. A percentage of 33.8 of the children had relevant trauma related findings in the CT scan. In 2 children, (2.8 %) 3 diagnoses (2.2 %) were initially missed. After reevaluation of the CT data, all diagnoses were identified. Thus, the accuracy of our algorithm in children was 100 %. In children, our algorithm detected all injuries, but only one third of the children had relevant trauma related findings in the CT scan. In order to reduce radiation exposure but preserve the advantages of CT, a new algorithm was developed with more flexibility taking the child's age and mental status more into account as well as clinical findings. The mechanism of injury itself is not anymore an indication for CT scanning.

Psychiatric emergencies in prehospital emergency medical systems: a prospective comparison of two urban settings.

BACKGROUND: Psychiatric emergency situations (PES) are of high importance to the German prehospital physician-based emergency medical system. So far, however, no prospective studies regarding the incidence of PES have been performed, neither have effects of training programs on diagnostic and therapeutic accuracy been studied. METHOD: The protocols of two emergency medical services (EMS) were collected and analyzed prospectively. Emergency physicians (EPs) in Kaiserslautern (KL) attended a standardized educational program and underwent daily supervision. EPs in Homburg (HOM) had not been informed about the study. In KL, sociodemographic variables were collected. An investigator who was not involved in the individual EMS mission assessed the correct classification of PES. RESULTS: Among all calls for an EP, 11.8% were classified as PES. There was no difference between the two centers. Correct classification of PES in KL was significantly higher than that in HOM (94.3% vs. 80.6%). Documentation of suicidal behavior was deficient in both centers. EPs in KL gave verbal crisis intervention significantly more often, administered less medication overall, and dispensed more specific drugs in psychotic disorders and significantly less drugs in substance abuse disorders. Patients were more often treated at the scene and were less often transported to a hospital. Some sociodemographic variables were associated with psychiatric morbidity of treatment. CONCLUSION: Accounting for 12% of all missions, psychiatric emergencies are a frequent reason for calls for EPs, equaling trauma-related and neurological emergencies. The most frequent reasons for calls were alcohol intoxication, states of agitation and suicidal behavior. The diagnostic and therapeutic accuracy of EPs may be improved with a concise standardized teaching program.

Hypertonic-hyperoncotic solutions reduce the release of cardiac troponin I and s-100 after successful cardiopulmonary resuscitation in pigs.

UNLABELLED: In some patients, cardiopulmonary resuscitation (CPR) can revive spontaneous circulation (ROSC). However, neurological outcome often remains poor. Hypertonic-hyperoncotic solutions (HHS) have been shown to improve microvascular conductivity after regional and global ischemia. We investigated the effect of infusion of HHS in a porcine CPR model. Cardiac arrest was induced by ventricular fibrillation. Advanced cardiac life support was begun after 4 min of nonintervention and 1 min of basic life support. Upon ROSC, the animals randomly received 125 mL of either normal saline (placebo, n = 8) or 7.2% NaCl and 10% hydroxyethyl starch 200,000/0.5 (HHS, n = 7). Myocardial and cerebral damage were assessed by serum concentrations of cardiac troponin I and astroglial protein S-100, respectively, up to 240 min after ROSC. In all animals, the levels of cardiac troponin I and S-100 increased after ROSC (P < 0.01). This increase was significantly blunted in animals that received HHS instead of placebo. The use of HHS in the setting of CPR may provide a new option in reducing cell damage in postischemic myocardial and cerebral tissues. IMPLICATIONS: Infusion of hypertonic-hyperoncotic solutions (HHS) after successful cardiopulmonary resuscitation in pigs significantly reduced the release of cardiac troponin I and cerebral protein S-100, which are sensitive and specific markers of cell damage. Treatment with HHS may provide a new option to improve the outcome of cardiopulmonary resuscitation.