Remote specialist assessment for intravenous thrombolysis of acute ischaemic stroke by telephone.

OBJECTIVE: To describe the process, efficacy and safety of intravenous thrombolysis for acute ischaemic stroke in an emergency department (ED) setting with remote specialist support through structured telephone consultation. DESIGN: Retrospective case series. SETTING: Three EDs within a single stroke service in northern England. PARTICIPANTS: Patients with acute stroke given intravenous thrombolytic therapy between 6 September 2007 and 1 October 2010. OUTCOME MEASURES: Combined death and dependency at 90 days (0-2 on the modified Rankin Scale for a good outcome vs 3-6 for a poor outcome), door-to-needle time, neurological impairment and presence of treatment related haemorrhage. RESULTS: 192 patients received intravenous thrombolysis. 94/178 (53%) were treated after remote specialist assessment. Data available from 178 patients showed similar proportions with a good outcome after each mode of assessment (56% in person and 48% by telephone). The median door-to-needle time was 8 min faster in the group assessed in person (65 vs 73 min by telephone) but there was no difference in neurological outcome or symptomatic haemorrhage. After review in person, the stroke specialist tended to treat patients with a higher median modified Rankin Scale (1 vs 0 by telephone). CONCLUSION: In a single stroke service the clinical outcomes of treatment with intravenous thrombolysis were similar whether assessment was performed after specialist review in person or via a telemedicine service consisting of ED staff training, telephone consultation and remote review of brain imaging by a stroke specialist.

Medical education, simulation and uncertainty.

BACKGROUND: Foundation doctors often feel underprepared to cope with uncertainty, particularly in an acute setting. Simulation is an established method for teaching about the management of acutely unwell patients, yet simulated cases are often simplified to ensure that a given learning outcome is reached. This approach may present learners with challenges in clinical practice when more complex nuanced cases are encountered. We explored final-year medical students' perceptions of clinical uncertainty when facing an 'authentically' complex simulated patient. METHODS: We adapted a simulation scenario in an attempt to replicate clinical uncertainty. The simulated patient had a confused history, only mildly deranged physiology, no current clear diagnosis and no diagnostic investigations yet available. Students engaged in debriefs facilitated by the researchers, which employed advocacy and enquiry to help students to reflect on their simulations (the 'Diamond Approach'). These were transcribed, coded and analysed thematically. RESULTS: Students found the 'uncertainty' simulation more challenging than a 'typical' simulation. Students found it disheartening when the patient had no clear diagnosis and expected 'an answer'. Students described task fixation and/or inaction in the face of uncertainty, struggled to identify appropriate times to seek senior support and were confused about their role in managing complex cases. DISCUSSION: We propose that this session prompted valuable discussion amongst students about how to react to clinical uncertainty. Students generally perceived the simulation as being useful. Affording space for reflection and allowing students to consider strategies for coping with uncertainty may help them when managing complex cases as Foundation doctors.