Virtual Telesimulation for Medical Students During the COVID-19 Pandemic.

PROBLEM: In March 2020, the novel coronavirus 2019 (COVID-19) became a global pandemic. Medical schools around the United States faced difficult decisions, temporarily suspending hospital-based clerkship rotations for medical students due to potential shortages of personal protective equipment and a need to social distance. This decision created a need for innovative, virtual learning opportunities to support undergraduate medical education. APPROACH: Educators at Yale School of Medicine developed a novel medical student curriculum converting high-fidelity, mannequin-based simulation into a fully online virtual telesimulation format. By using a virtual videoconferencing platform to deliver remote telesimulation as an immersive educational experience for widely dispersed students, this novel technology retains the experiential strengths of simulation-based learning while complying with needs for social distancing during the pandemic. The curriculum comprises simulated clinical scenarios that include live patient actors; facilitator interactions; and real-time assessment of vital signs, labs, and imaging. Each 90-minute session includes 2 sets of simulation scenarios and faculty-led teledebriefs. A team of 3 students performs the first scenario, while an additional team of 3 students observes. Teams reverse roles for the second scenario. OUTCOMES: The 6-week virtual telesimulation elective enrolled the maximum 48 medical students and covered core clinical clerkship content areas. Communication patterns within the virtual telesimulation format required more deliberate turn-taking than normal conversation. Using the chat function within the videoconferencing platform allowed teams to complete simultaneous tasks. A nurse confederate provided cues not available in the virtual telesimulation format. NEXT STEPS: Rapid dissemination of this program, including online webinars and live demonstration sessions with student volunteers, supports the development of similar programs at other universities. Evaluation and process improvement efforts include planned qualitative evaluation of this new format to further understand and refine the learning experience. Future work is needed to evaluate clinical skill development in this educational modality.

Covid-19 and the N95 respirator shortage: Closing the gap.

Due to extreme shortages of personal protective equipment caused by the COVID-19 pandemic, many healthcare workers will be forced to recycle protective masks intended for disposal after a single use. We propose investigating the use of ultraviolet germicidal irradiation to sterilize masks of SARS-CoV-2 for safer reuse.

Multiple Fentanyl Overdoses - New Haven, Connecticut, June 23, 2016.

On the evening of June 23, 2016, a white powder advertised as cocaine was purchased off the streets from multiple sources and used by an unknown number of persons in New Haven, Connecticut. During a period of less than 8 hours, 12 patients were brought to the emergency department (ED) at Yale New Haven Hospital, experiencing signs and symptoms consistent with opioid overdose. The route of intoxication was not known, but presumed to be insufflation ("snorting") in most cases. Some patients required doses of the opioid antidote naloxone exceeding 4 mg (usual initial dose = 0.1-0.2 mg intravenously), and several patients who were alert after receiving naloxone subsequently developed respiratory failure. Nine patients were admitted to the hospital, including four to the intensive care unit (ICU); three required endotracheal intubation, and one required continuous naloxone infusion. Three patients died. The white powder was determined to be fentanyl, a drug 50 times more potent than heroin, and it included trace amounts of cocaine. The episode triggered rapid notification of public health and law enforcement agencies, interviews of patients and their family members to trace and limit further use or distribution of the fentanyl, immediate naloxone resupply and augmentation for emergency medical services (EMS) crews, public health alerts, and plans to accelerate naloxone distribution to opioid users and their friends and families. Effective communication and timely, coordinated, collaborative actions of community partners reduced the harm caused by this event and prevented potential subsequent episodes.

Toxic industrial chemicals and chemical weapons: exposure, identification, and management by syndrome.

Toxidromes aid emergency care providers in the context of the patient presenting with suspected poisoning, unexplained altered mental status, unknown hazardous materials or chemical weapons exposure, or the unknown overdose. The ability to capture an adequate chemical exposure history and to recognize toxidromes may reduce dependence on laboratory tests, speed time to delivery of specific antidote therapy, and improve selection of supportive care practices tailored to the etiologic agent. This article highlights elements of the exposure history and presents selected toxidromes that may be caused by toxic industrial chemicals and chemical weapons. Specific antidotes for toxidromes and points regarding their use, and special supportive measures, are presented.

Clinical guidelines for responding to chemical, biological, radiological, nuclear and trauma/burn mass casualty incidents: Quick reference guides for emergency department staff.

The word 'DISASTER' may be used as a mnemonic for listing the critical elements of emergency response. The National Disaster Life Support Education Foundation's (NDLSEC) DISASTER paradigm emphasises out-of-hospital emergency response and includes the following elements: (1) detect; (2) incident command system; (3) security and safety; (4) assessment; (5) support; (6) triage and treatment; (7) evacuate; and (8) recovery. This paper describes how the DISASTER paradigm was used to create a series of clinical guidelines to assist the preparedness effort of hospitals for mitigating chemical, biological, radiological, nuclear incidents or explosive devices resulting in trauma/burn mass casualty incidents (MCIs) and their initial response to these events. Descriptive information was obtained from observations and records associated with this project. The information contributed by a group of subject matter experts in disaster medicine, at the Yale New Haven Health System Center for Emergency Preparedness and Disaster Response was used to author the clinical guidelines. Akin to the paradigm developed by the NDLSEC for conducting on-scene activities, the clinical guidelines use the letters in the word 'disaster' as a mnemonic for recalling the main elements required for mitigating MCIs in the hospital emergency department.

The global burden of road injury: its relevance to the emergency physician.

Background. Road traffic crash fatalities in the United States are at the lowest level since 1950. The reduction in crash injury burden is attributed to several factors: public education and prevention programs, traffic safety policies and enforcement, improvements in vehicle design, and prehospital services coupled with emergency and acute trauma care. Globally, the disease burden of road traffic injuries is rising. In 1990, road traffic injuries ranked ninth in the ten leading causes of the global burden of disease. By 2030, estimates show that road traffic injuries will be the fifth leading causes of death in the world. Historically, emergency medicine has played a pivotal role in contributing to the success of the local, regional, and national traffic safety activities focused on crash and injury prevention. Objective. We report on the projected trend of the global burden of road traffic injuries and fatalities and describe ongoing global initiatives to reduce road traffic morbidity and mortality. Discussion. We present key domains where emergency medicine can contribute through international collaboration to address global road traffic-related morbidity and mortality. Conclusion. International collaborative programs and research offer important opportunities for emergency medicine physicians to make a meaningful impact on the global burden of disease.

Creation and Delphi-method refinement of pediatric disaster triage simulations.

OBJECTIVE: There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy. METHODS: We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios. RESULTS: After two rounds of the modified Delphi, consensus for expected triage level was >85% for 28 of 30 victims, with the remaining two achieving >85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10 instances of noncorrelation between evaluations and simulation. CONCLUSIONS: The modified Delphi process, used to derive novel PDT simulation and evaluation tools, yielded a high degree of consensus among the SMEs, and eliminated biases toward specific PDT strategies in the evaluations. The simulations and evaluation tools may now be tested for reliability and validity as part of a prehospital PDT curriculum.

Mass arsenic poisoning and the public health response in Maine.

Created in the wake of the September 11, 2001 terrorist attacks, Maine's Office of Public Health Emergency Preparedness within the Maine Center for Disease Control and Prevention undertook a major reorganization of epidemiology and laboratory services and began developing relationships with key partners and stakeholders, and a knowledgeable and skilled public health emergency preparedness workforce. In 2003, these newly implemented initiatives were tested extensively during a mass arsenic poisoning at the Gustav Adolph Lutheran Church in the rural northern community of New Sweden, Maine. This episode serves as a prominent marker of how increased preparedness capabilities, as demonstrated by the rapid identification and administration of antidotes and effective collaborations between key partners, can contribute to the management of broader public health emergencies in rural areas.

Use of haloperidol in PCP-intoxicated individuals.

CONTEXT: Emergency medical workers often experience violence while performing their job functions. Phencyclidine (PCP)-intoxicated patients are often violent and difficult to control physically. A chemical restraint is frequently needed to assist in protecting both patients and staff from agitated persons. OBJECTIVE: This study evaluated haloperidol as a chemical restraint in PCP-intoxicated patients. METHODS: This is a retrospective case series of all PCP-positive patients who received haloperidol for behavioral control from April 2008 to April 2011 at a single large (944 bed), urban, tertiary-care hospital. All patients receiving haloperidol and having a toxicology screen positive for PCP were identified using an electronic medical record. Identified cases were then manually reviewed by investigators for adverse events. RESULTS: Subjects included 59 adult patients who were acutely agitated requiring chemical restraint or sedation with haloperidol, and who tested positive for PCP. There were 20 females and 39 males, ranging in age from 19 to 54 years. Patients received haloperidol via the PO, IM, or IV routes in doses ranging from 1 to 10 mg. There were two adverse events (mild hypoxia and mild hypotension) found during chart review; neither were serious nor required change in patient disposition. CONCLUSIONS: In this study, haloperidol does not seem to cause harm when used in the management of PCP-intoxicated patients. Caution must always be exercised in the use of chemical restraint; further prospective study is warranted.

Disaster and exercise performance information collection tool: capturing observations in four minutes or less.

The objectives of the work described in this paper were to: (a) identify existing gaps in data collection, processing and dissemination across all types of emergencies; (b) build a tool that permits documentation, manipulation and propagation of relevant observations in emergency preparedness exercises or real-world incidents to inform critical decision makers in real time and to facilitate the elaboration of lessons learned, best practices and pioneering strategies for the management of future disasters; (c) validate the efficacy of the tool for collecting, processing and disseminating disaster-related information, through its integration in a series of exercises. The disaster and exercise performance information collection tool (DEPICT) was developed to address needs identified via the analysis of survey responses provided by representatives of military and civilian organisations with disaster response experience. Consensus discussions were held to identify criteria and operational parameters for the tool. As the development of DEPICT progressed, feedback and recommendations for improvements were provided to the developers, who incorporated the recommendations in successive iterations, resulting in increased refinements of the tool. DEPICT was subsequently tested for feasibility through operations-based exercises centred on catastrophic earthquakes in three diverse geographic locations of the USA. Feedback regarding DEPICT's functional performance during the exercises was used to inform further refinements to the program. The authors developed the DEPICT software on a PHP platform to accomplish two goals: (1) offer a core that supports user interaction and data management requirements (eg data capture, transmission and storage); (2) present a user-friendly interface with a shallow learning curve to facilitate a better user experience. DEPICT is a user-friendly, web-based application that is accessible through various mobile web-enabled devices. The application allows responders, emergency planners and exercise evaluators to capture written and photographic field observations, on average, in four minutes or less per observation. These observations may be further processed or formatted offsite by analysts, prior to their submission for final exercise performance evaluation. Ultimately, the data form the basis of after-action reports, which, in turn, underpin future decision making and improved disaster response practices.

Resource allocation: an approach for enhancing hospital resiliency.

The objective of the work described in this paper was to develop the Hospital Emergency Support Function (HESF) model, which could be used by hospitals to augment medical surge capacity based on the reallocation of internal hospital personnel, in the wake of a catastrophic natural or manmade disaster. A group of subject matter experts, including clinicians with disaster response experience, hospital emergency coordinators and business continuity planners, was assembled to conceptualise the basic framework of the HESF model. The model was validated via feedback from a panel of decision makers at Yale-New Haven Hospital and development of a consensus among the panel, using a modified Delphi method. Hospital personnel and departments were reviewed, evaluated and stratified according to their latent contributions to medical surge capacity. Those pivotal to medical surge capacity were deemed HESFs, whereas those ancillary to medical surge capacity were considered non-critical or ancillary functions. Based on this classification, personnel assigned to non-critical hospital departments were identified as potentially divertible to HESFs, ie available to enhance medical surge capacity during a catastrophic emergency. The activation of the HESF model provides an alternative to utilising external resources for enhancing staffing during a medical surge event. The HESF model is based on the National Response Framework Emergency Support Functions and relies solely on internal hospital personnel to augment medical surge capacity in the event of a medical and public health crisis.

Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care.

STUDY OBJECTIVE: We developed recommendations for antidote stocking at hospitals that provide emergency care. METHODS: An expert panel representing diverse perspectives (clinical pharmacology, clinical toxicology, critical care medicine, clinical pharmacy, emergency medicine, internal medicine, pediatrics, poison centers, pulmonary medicine, and hospital accreditation) was formed to create recommendations for antidote stocking. Using a standardized summary of the medical literature, the primary reviewer for each antidote proposed guidelines for antidote stocking to the full panel. The panel used a formal iterative process to reach their recommendation for the quantity of an antidote that should be stocked and the acceptable period for delivery of each antidote. RESULTS: The panel recommended consideration of 24 antidotes for stocking. The panel recommended that 12 of the antidotes be available for immediate administration on patient arrival. In most hospitals, this period requires that the antidote be stocked in the emergency department. Another 9 antidotes were recommended for availability within 1 hour of the decision to administer, allowing the antidote to be stocked in the hospital pharmacy if the hospital has a mechanism for prompt delivery of antidotes. The panel identified additional antidotes that should be stocked by the hospital but are not usually needed within the first hour of treatment. The panel recommended that each hospital perform a formal antidote hazard vulnerability assessment to determine the need for antidote stocking in that hospital. CONCLUSION: The antidote expert recommendations provide a tool to be used in creating practices for appropriate and adequate antidote stocking in hospitals that provide emergency care.