Two-thumb vs. two-finger chest compression in an infant model of prolonged cardiopulmonary resuscitation

OBJECTIVE

Previous experiments in the authors' swine lab have shown that cardiopulmonary resuscitation (CPR) using two-thumb chest compression with a thoracic squeeze (TT) produces higher blood and perfusion pressures when compared with the American Heart Association (AHA)-recommended two-finger (TF) technique. Previous studies were of short duration (1-2 minutes). The hypothesis was that TT would be superior to TF during prolonged CPR in an infant model.

METHODS

This was a prospective, randomized crossover experiment in a laboratory setting. Twenty-one AHA-certified rescuers performed basic CPR for two 10-minute periods, one with TT and the other with TF. Trials were separated by 2-14 days, and the order was randomly assigned. The experimental circuit consisted of a modified manikin with a fixed-volume arterial system attached to a neonatal monitor via an arterial pressure transducer. The arterial circuit was composed of a 50-mL bag of normal saline solution (air removed) attached to the manikin chest plate and connected to the transducer with a 20-gauge intravenous catheter and tubing. Rescuers were blinded to the arterial pressure tracing. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded in mm Hg, and pulse pressures (PPs) were calculated. Data were analyzed with two-way repeated-measures analysis of variance. Sphericity assumed modeling, with Greenhouse-Geisser and Huynh-Feldt adjustments, was applied.

RESULTS

Marginal means for TT SBP (68.9), DBP (17.6), MAP (35.3), and PP (51.4) were higher than for TF SBP (44.8), DBP (12.5), MAP (23.3), and PP (32.2). All four pressures were significantly different between the two techniques (p< or =0.001).

CONCLUSION

In this infant CPR model, TT chest compression produced higher MAP, SBP, DBP, and PP when compared with TF chest compression during a clinically relevant duration of prolonged CPR.

Direct observation of residents in the emergency department: a structured educational program

OBJECTIVES

The objective was to describe the implementation of a program of structured direct observation of emergency medicine (EM) residents during clinical shifts in the emergency department (ED).

METHODS

The authors developed a program in which an observer spent 4 to 5 hours with each resident, without intervening in the clinical encounters. A structured data form was developed to document the resident's performance in a number of defined clinical areas relevant to patient care and mastery of the core competencies. Individual strengths and weaknesses were noted, and the observer provided directed feedback at the end of the session.

RESULTS

Over an 18-month period, 32 EM residents were observed during their ED shifts. The sessions not only provided specific information on individual residents' performances, but also identified areas where the residency program curriculum could be enhanced and provided a means of assessing mastery of the core competencies. In addition, the program provided an opportunity to give detailed and timely directed feedback to residents. Both residents and attending staff found the sessions acceptable and useful.

CONCLUSIONS

Implementation of a structured direct observation program was feasible and well received and provided insight into the strengths and weaknesses of residents both individually and as a group.

Urosepsis associated with vaginal pessary use

Conservative management of genital prolapse in older women uses vaginal pessaries. Infectious complications of these devices, attributable in some instances to poor routine maintenance, are uncommonly reported. We present 2 cases of genitourinary sepsis associated with unsuspected pessary use and discuss the spectrum of complications reported with these appliances.

Putting Theory to Practice: Applying Cognitive Load Theory to Resident Medical Education

OBJECTIVE

We built 2 versions of an asynchronous pediatric orthopedic educational intervention for emergency medicine residents and sought to compare the two. We hypothesized that the version incorporating more instructional scaffolding in the form of a cognitive aid (CA) would optimize germane cognitive load for our target novice learners and result in higher test scores.

METHODS

Learners were block randomized to either a "CA" or "non-CA" arm, each containing a random set of 18 modules. The CA arm incorporated an orthopedic fracture classification chart embedded within the diagnostic questions to guide the learner in forming a diagnosis. The non-CA arm was designed with more active learning as the classification chart was provided only after each diagnostic answer submission. For both arms, the final 6 modules completed per learner were scored. Learners also completed a perceived cognitive load assessment tool measured on a 10-point Likert scale.

RESULTS

Learners in the non-CA arm had a mean total score on the testing modules of 33% correct compared with a mean total score of 44% correct for learners in the CA arm (mean difference, 11; 95% confidence interval, 4%-19%, P = 0.005). There was a trend for the CA arm to have lower perceived overall cognitive load scores; however, this did not reach statistical significance.

CONCLUSIONS

Emergency medicine residents performed better after completing the CA version of our educational intervention. Applying cognitive load theory to an educational intervention may increase its success among target learners.

The Council of Emergency Medicine Residency Directors Academy for Scholarship Coaching Program: Addressing the Needs of Academic Emergency Medicine Educators

Introduction

Didactic lectures remain fundamental in academic medicine; however, many faculty physicians do not receive formal training in instructional delivery. In order to design a program to instill and enhance lecture skills in academic emergency medicine (EM) physicians we must first understand the gap between the current and ideal states.

Methods

In 2012 the Council of Emergency Medicine Residency Directors (CORD) Academy for Scholarship designed a novel coaching program to improve teaching skills and foster career development for medical educators based on literature review and known teaching observation programs. In order to inform the refinement of the program, we performed a needs assessment of participants. Participants’ needs and prior teaching experiences were gathered from self-reflection forms completed prior to engaging in the coaching program. Two independent reviewers qualitatively analyzed data using a thematic approach.

Results

We analyzed data from 12 self-reflection forms. Thematic saturation was reached after nine forms. Overall inter-rater agreement was 91.5%. We categorized emerging themes into three domains: participant strengths and weaknesses; prior feedback with attempts to improve; and areas of desired mentorship. Several overlapping themes and subthemes emerged including factors pertaining to the lecturer, the audience/learner, and the content/delivery.

Conclusion

This study identified several areas of need from EM educators regarding lecture skills. These results may inform faculty development efforts in this area. The authors employed a three-phase, novel, national coaching program to meet these needs.

Comparison of the Standardized Video Interview and Interview Assessments of Professionalism and Interpersonal Communication Skills in Emergency Medicine

OBJECTIVES

The Association of American Medical Colleges Standardized Video Interview (SVI) was recently added as a component of emergency medicine (EM) residency applications to provide additional information about interpersonal communication skills (ICS) and knowledge of professionalism (PROF) behaviors. Our objective was to ascertain the correlation between the SVI and residency interviewer assessments of PROF and ICS. Secondary objectives included examination of 1) inter- and intrainstitutional assessments of ICS and PROF, 2) correlation of SVI scores with rank order list (ROL) positions, and 3) the potential influence of gender on interview day assessments.

METHODS

We conducted an observational study using prospectively collected data from seven EM residency programs during 2017 and 2018 using a standardized instrument. Correlations between interview day PROF/ICS scores and the SVI were tested. A one-way analysis of variance was used to analyze the association of SVI and ROL position. Gender differences were assessed with independent-groups t-tests.

RESULTS

A total of 1,264 interview-day encounters from 773 unique applicants resulted in 4,854 interviews conducted by 151 interviewers. Both PROF and ICS demonstrated a small positive correlation with the SVI score (r = 0.16 and r = 0.17, respectively). ROL position was associated with SVI score (p < 0.001), with mean SVI scores for top-, middle-, and bottom-third applicants being 20.9, 20.5, and 19.8, respectively. No group differences with gender were identified on assessments of PROF or ICS.

CONCLUSIONS

Interview assessments of PROF and ICS have a small, positive correlation with SVI scores. These residency selection tools may be measuring related, but not redundant, applicant characteristics. We did not identify gender differences in interview assessments.

Implementation of a Novel Conference Series on Clinical Practice Variations Provides an Opportunity for Constructive Discussion of Faculty Practice Patterns: Do as We Say? … or Do as We Do?

BACKGROUND

Although evidence-based medicine (EBM) is routinely used to guide management in the emergency department, there is still considerable variation in clinical practice. Trainees may not fully appreciate the reasons for these clinical practice variations (CPVs) and may find it frustrating when they encounter them. We used areas of CPV among our faculty as the basis for resident educational sessions and assessed the perceived utility of these sessions.

METHODS

Topics were identified when residents noticed significant variability among the faculty in their management of particular clinical presentations. Sessions were conducted by facilitator-led reviews of EBM guidelines, by faculty panel discussions of their management rationale where EBM guidelines are not available, or by pro-con debates. Residents were surveyed after the initial sessions to assess the utility of this series and changes in their understanding of CPV.

RESULTS

There was a 72% response rate. The percentage of residents who were frustrated with CPV decreased from 64% to 35%; the percentage who felt that the presence of CPV enhanced their learning increased from 19% to 48%. Sixty-five percent felt that the educational series contributed to decreased frustration, 77% felt that the sessions helped them understand why CPV occurs, and 93% felt that they helped their overall learning.

CONCLUSION

Explicit discussion and exploration of CPV in an educational setting can provide multiple benefits. Trainees may gain a better understanding of why CPV occurs and of the rationale behind practice variations. Faculty may benefit from analyzing CPV to determine whether these truly represent the "art of medicine."

Coaching educators: Impact of a novel national faculty development program for didactic presentation skills

BACKGROUND

Didactic lectures remain common in medical education. Many faculty physicians do not receive formal training on public presentations or leading instructional sessions. Coaching has emerged in medical education with the potential to positively impact skills. We sought to evaluate a novel, national faculty peer-coaching program created to improve lecture presentation skills and foster career development.

METHODS

This was a mixed-methods study of participant and faculty perceptions after completing the Council of Residency Directors in Emergency Medicine Academy Coaching Program. Participants completed an online evaluative survey consisting of multiple choice and Likert-type items. Program coaches participated in semistructured interviews. Descriptive statistics were reported for survey data. Thematic qualitative analysis by two independent reviewers was performed on interview data.

RESULTS

During 2012 to 2017, a total of 30 participants and 11 coaches from 37 residency programs across the United States engaged in the program. Twenty-four (80%) participants completed the survey. Eight (73%) coaches participated in semistructured interviews. Data were collected between October and December 2018. The mean ± SD numbers of national presentations participants had given before and after the coaching program were 6.92 ± 7.68 and 16.42 ± 15.43, respectively. Since their coaching, most participants (87.5%) have been invited to give a lecture at another institution. Many participants felt that the program improved their lecture evaluations, public speaking, ability to engage an audience, and professional development. Almost all (92%) would recommend the program to a colleague. The coaches perceived multiple benefits including improved skills, self-reflection, networking, career advancement, and personal fulfillment. Suggestions for improvement included improved administrative processes, more clear expectations, increased marketing, and increased participant and coach engagement.

CONCLUSION

Participants and coaches perceived multiple benefits from this novel, national faculty coaching program. With identification of the success, challenges, and suggestions for improvement, others may benefit as they develop coaching programs in medical education.

Establishing an Elective Rotation Director and Its Effect on Elective Opportunities and Satisfaction

Elective rotations are valuable, allowing trainees to personalize their educational experience, focus on areas of weakness, and offer personal and professional development. Emergency medicine (EM) residency program elective rotations may be limited due to the absence of awareness of opportunities and administrative support. We sought to increase the breadth of elective rotation opportunities, improve residents' satisfaction with their elective rotations, and enhance the opportunities for clinical training. To increase the breadth of our elective rotation opportunities, we established an elective rotation director-a dedicated faculty member to aid in elective planning and provide administrative support. This faculty member met with all residents during their second year, coordinated new electives with the graduate medical education office, and assisted with administrative tasks. Ten new rotations (two local, five domestic away, three international away) were established during the position's first two years, increasing available rotations from nine to 19. A survey was sent to graduates of the program two years before and two years after the position was established to inquire about their elective experience. Of 64 graduates, 49 (76.6%) participated in the survey. Graduates exposed to the dedicated faculty member reported increased exposure to novel learning environments (p<0.001), improved wellness (p<0.001), and were more likely than pre-director graduates to choose the same elective rotation (p=0.006). Programs with multiple elective rotations may benefit more from this position, but additional resources may be needed given the associated increase in administrative time.