Effect of Repetitive Simulation Training on Emergency Medical Services Team Performance in Simulated Pediatric Medical Emergencies

OBJECTIVE

Emergency medical services (EMS) professionals infrequently transport children leading to difficulty in recognition and management of pediatric critical illness. Simulation provides an opportunity to train EMS professionals on pediatric emergencies. The objective of this study was to examine the effect of serial simulation training over 6 months on EMS psychomotor and cognitive performance during team-based care.

METHODS

This was a longitudinal prospective study of a simulation curriculum enrolling EMS professionals over a 6-month period during which they performed three high-fidelity simulations at 3-month intervals. The simulation scenarios included a 15-month-old seizure (T₀), 1-month-old with hypoglycemia (T₁), and 4-year-old clonidine ingestion (T₂). All scenarios were standardized and required recognition and management of respiratory failure and decompensated shock. Scenarios were videotaped and two investigators scored EMS team interventions during simulations using a standardized scoring tool. Inter-rater reliability was assessed on 30% of videos using kappa analysis. Volumes of administered intravenous fluid (IVF) and medications were measured to assess for errors in administration. The primary outcome was the change in scenario score from T₀ to T₂.

RESULTS

A total of 135 team-based simulations were conducted over the study period (48, 40, and 47 at T₀, T₁, and T₂, respectively). Inter-rater reliability between reviewers was very good (κ = 0.7). Median simulation score improved from T₀ to T₂ (24 vs 31, p < 0.001, maximum score possible = 42). The proportion of completed tasks increased across multiple categories including improved recognition of respiratory decompensation (19% vs. 56%), management of the pediatric airway (44% vs. 88%), and timeliness of vascular access (10% vs. 38%). Correct IVF administration varied by scenario (25% vs. 52% vs. 30%, p = 0.02).

CONCLUSION

Serial simulation improved EMS team-based care in both recognition and management of pediatric emergencies. A standardized pediatric simulation curriculum can be used to train EMS professionals on pediatric emergencies and improve performance.

Child Abuse Recognition Training for Prehospital Providers Using Deliberate Practice

BACKGROUND

In most states, prehospital professionals (PHPs) are mandated reporters of suspected abuse but cite a lack of training as a challenge to recognizing and reporting physical abuse. We developed a learning platform for the visual diagnosis of pediatric abusive versus non-abusive burn and bruise injuries and examined the amount and rate of skill acquisition.

METHODS

This was a prospective cross-sectional study of PHPs participating in an online educational intervention containing 114 case vignettes. PHPs indicated whether they believed a case was concerning for abuse and would report a case to child protection services. Participants received feedback after submitting a response, permitting deliberate practice of the cases. We describe learning curves, overall accuracy, sensitivity (diagnosis of abusive injuries) and specificity (diagnosis of non-abusive injuries) to determine the amount of learning. We performed multivariable regression analysis to identify specific demographic and case variables associated with a correct case interpretation. After completing the educational intervention, PHPs completed a self-efficacy survey on perceived gains in their ability to recognize cutaneous signs of abuse and report to social services.

RESULTS

We enrolled 253 PHPs who completed all the cases; 158 (63.6%) emergency medical technicians (EMT), 95 (36.4%) advanced EMT and paramedics. Learning curves demonstrated that, with one exception, there was an increase in learning for participants throughout the educational intervention. Mean diagnostic accuracy increased by 4.9% (95% CI 3.2, 6.7), and the mean final diagnostic accuracy, sensitivity, and specificity were 82.1%, 75.4%, and 85.2%, respectively. There was an increased odds of getting a case correct for bruise versus burn cases (OR = 1.4; 95% CI 1.3, 1.5); if the PHP was an Advanced EMT/Paramedic (OR = 1.3; 95% CI 1.1, 1.4) ; and, if the learner indicated prior training in child abuse (OR = 1.2; 95% CI 1.0, 1.3). Learners indicated increased comfort in knowing which cases should be reported and interpreting exams in children with cutaneous injuries with a median Likert score of 5 out of 6 (IQR 5, 6).

CONCLUSION

An online module utilizing deliberate practice led to measurable skill improvement among PHPs for differentiating abusive from non-abusive burn and bruise injuries.

Utilization of Intravenous Catheters by Prehospital Providers during Pediatric Transports

INTRODUCTION

Prehospital intravenous (IV) access in children may be difficult and time-consuming. Emergency Medical Service (EMS) protocols often dictate IV placement; however, some IV catheters may not be needed. The scene and transport time associated with attempting IV access in children is unknown. The objective of this study is to examine differences in scene and transport times associated with prehospital IV catheter attempt and utilization patterns of these catheters during pediatric prehospital encounters.

METHODS

Three non-blinded investigators abstracted EMS and hospital records of children 0-18 years of age transported by EMS to a pediatric emergency department (ED). We compared patients in which prehospital IV access was attempted to those with no documented attempt. Our primary outcome was scene time. Secondary outcomes include utilization of the IV catheter in the prehospital and ED settings and a determination of whether the catheter was indicated based on a priori established criteria (prehospital IV medication administration, hypotension, GCS < 13, and ICU admission).

RESULTS

We reviewed 1,138 records, 545 meeting inclusion criteria. IV catheter placement was attempted in 27% (n = 149) with success in 77% (n = 111). There was no difference in the presence of hypotension or median GCS between groups. Mean scene time (12.5 vs. 11.8 minutes) and transport time (16.9 vs. 14.6 minutes) were similar. Prehospital IV medications were given in 38.7% (43/111). One patient received a prehospital IV medication with no alternative route of administration. Among patients with a prehospital IV attempt, 31% (46/149) received IV medications in the ED and 23% (34/396) received IV fluids in the ED. Mean time to use of the IV in the ED was 70 minutes after arrival. Patients with prehospital IV attempt were more likely to receive IV medication within 30 minutes of ED arrival (39.1% vs. 19.0%, p = 0.04). Overall, 34.2% of IV attempts were indicated.

CONCLUSIONS

Prehospital IV catheter placement in children is not associated with an increase in scene or transport time. Prehospital IV catheters were used in approximately one-third of patients. Further study is needed to determine which children may benefit most from IV access in the prehospital setting.

Floquet-Bloch solutions in a sawtooth photonic crystal

Band structure of a sawtooth photonic crystal for optical wave propagation along the axis of periodicity is investigated. Floquet-Bloch solutions are found and illustrated for the bandgaps, allowed bands, and bandedges of the crystal. Special attention is given to the cases where Floquet-Bloch solutions become periodic functions.

A 6-month prospective study of injury in Gaelic football

OBJECTIVE

To describe the injury incidence in Gaelic football.

METHODS

A total of 83 players from three counties were interviewed monthly about their injury experience, during the 6 months of the playing season.

RESULTS

The injury rate was 13.5/1000 h exposure to Gaelic football (95% CI, 10.9 to 16.6). There were nearly twice as many injuries during matches (64.4%, 95% CI, 54.1 to 73.6) as in training (35.6%, 95% CI, 26.4 to 49.5). The ankle was found to be the most commonly injured site (13.3%, 95% CI, 7.8 to 21.9). The musculotendinous unit accounted for nearly 1/3 of all injuries (31.1%). The tackle accounted for 27.8% of the injuries sustained (tackler 10%, 95% CI, 5.4 to 17.9; player being tackled 17.9%, 95% CI, 11.2 to 26.9). Of total match injuries, 56.9% (95% CI, 46.1 to 67.1) were experienced in the second half as opposed to 39.7% (95% CI, 29.8 to 50.5) in the first half.

CONCLUSIONS

Gaelic footballers are under considerable risk of injury. Greater efforts must be made to reduce this risk so that players miss less time from sport due to injury. Risk factors for injury in Gaelic football must now be investigated so that specific interventions may be established to reduce them.

Gendered health policies and a women's movement: the Gypsy case

Health concepts depend on socially constructed hygiene practices. Many accounts of "traditional" Gypsy hygiene make gender differentiation primary, implying that traditional health practices reinforce patriarchy and emphasizing the special needs of Gypsy women. This paper argues, however, that the position of women is contested in Romani society. Although prioritizing the more apparent health needs of women and small children appeals to health professionals, this cannot by itself create an effective critique of the health system's response to Gypsy needs. The emergence of a Gypsy women's movement has led to a new critique, and challenge to the victim image of women.