Use of Plastic Bag to Reduce Risks in Operators During Endotracheal Intubation of Patients With Coronavirus Disease 2019.

The rapid spread of coronavirus disease 2019 (COVID-19) has led to a large number of patients being admitted to hospitals, resulting in a near collapse of the medical system. The shortage of negative pressure isolation rooms and personal protective equipment is a potential problem. It is a pressing challenge to prevent the risk of infection in emergency physicians (EPs) during the endotracheal intubation of patients with COVID-19. We used a large clear plastic bag, cut an opening that covered the patient's head, and created a negative pressure environment inside the plastic bag using the hospital's medical gas pipeline system; thus reducing the amount of virus-containing aerosols leaked out and the risk of infection in the operators performing intubation. The video (http://www.caregiver.com.tw/Article.asp?ID=1258#article) about the detailed preparation of the plastic bag intubation kit (PBIK) has been posted on the website. This technique for safe endotracheal intubation in patients with COVID-19 is being used not only by EPs in Taiwan, but also by physicians and paramedics from other countries. Regarding designing the PBIK, our original intention was to use readily available materials to make tools that can improve the safety of the operators performing the intubations in situations where medical resources are exhausted. However, due to limited time and patients, further research is needed for validation.

Emergency physicians' role in telemedicine care during the coronavirus disease pandemic: Experiences from Taiwan.

Taiwan's response to the coronavirus disease pandemic received international recognition. Among various epidemic control measures, telemedicine services are provided for people under home quarantine. Although this service presents no policy, cost or equipment problems, the medical needs of people under home quarantine are diverse. Further, there are no clear guidelines regarding which specialists should be included in a multidisciplinary team. Moreover, many physicians are unwilling to participate in telemedicine, creating a big challenge for hospitals providing these services. Emergency physicians (EPs) have unique experiences in crisis management and can provide a number of effective public health measures. We advocate that EPs should be the first specialists to contact patients in a multidisciplinary team. Currently, there is a lack of literature on this subject, and Taiwan's epidemic control experience is used as an example to prove our viewpoint and provide recommendations for future EPs.

An Evaluation of the Use of Student Response Systems in Teaching Diagnostic Reasoning for Physicians.

BACKGROUND: Feedback is an aspect of teaching strategy that facilitates the learners to achieve expertise in the necessary skills for effective diagnostic reasoning. Several studies have demonstrated that student response systems (SRSs) are useful for enhancing learner engagement and obtaining immediate feedback. We aimed to examine the experiences of learners who used SRSs in a diagnostic reasoning class. METHODS: In 2016, an observational study was conducted on a 4-hour training course on "improving physicians' diagnostic process" that included 34 physicians. The Zuvio multimedia online interactive system was used. The learners could use smartphones to respond to the questions. A 5-point Likerttype scale quantitative questionnaire was designed to explore the viewpoints of the learners regarding the students' engagement, feedback, and outcomes. The learners were requested to complete a brief qualitative feedback form that included the following two sections: (1) the benefi ts and (2) the challenges of using SRSs. Qualitative and quantitative methods were used for data analyses. RESULTS: Total 32 participants (response rate: 94%) completed the questionnaire. Most respondents reported that using the SRSs enabled them to concentrate more effectively, express themselves in a stressfree environment, strengthen their interactions with peers and teachers, improve their participation in discussions, and obtain useful feedback. Three themes were identified from the qualitative results: (1) facilitating learning, (2) hardware limitations, and (3) question-development skills. CONCLUSION: The SRSs can be easily implemented and positively affect the teaching of diagnostic reasoning. However, teachers should develop question-development skills so that the systems function more effectively in the instruction of diagnostic reasoning.

Use of a Modified Fishbone Diagram to Analyze Diagnostic Errors in Emergency Physicians.

INTRODUCTION: Reilly et al. described a structured approach to the analysis of diagnostic errors by using a novel modifi ed fi shbone diagram. The application of this tool in emergency medicine had not previously been reported. The objective of this study is to use the modified fishbone diagram analysis method in examining the causes of common diagnostic errors committed by emergency physicians and the circumstances associating errors in cognitive processes. METHODS: Sixty-one cases of diagnostic errors involving ten board-certified emergency physicians (EPs) were identifi ed through a peer review process. Using a qualitative study approach, in-depth semi structured interviews with EPs was conducted. All interview audiotapes were transcribed verbatim. Content analysis was performed on all textual data to identify the factors underlying errors using the modified fishbone diagram. RESULTS: In 61 cases, 165 diagnostic errors were identified (2.7 per case). The underlying contributions to errors fell into 7 categories: cognitive process (54/61, 89%), specific presentation (32/61, 52%), clinical data gathering (24/61, 39%), organization issues (12/61, 20%), affective factors (9/61, 15%), context of care (9/61, 15%), and communication (5/61, 8%). Of these cognitive errors were the most common. However, only six cases occurred in isolation (6/54, 11%), with the remaining 48 cases (48/54, 89%) occurring with other types of errors, the most common being specific presentation (28/54, 52%) and clinical data gathering (24/54, 44%). CONCLUSIONS: The modified fishbone diagram is a useful tool to identify various categories of errors on diagnostic process in emergency department (ED). These fi ndings provide a basis on which to build a framework for teaching EPs how to avoid misdiagnoses in the ED setting.

Inaccurate or delayed diagnosis of hollow organ perforation by emergency physicians: using a qualitative approach to identify the causes.

BACKGROUND: Mistakes or delays in the diagnosis of hollow organ perforation may be detrimental to prognosis. Nonetheless, emergency physicians (EPs) are prone to misdiagnosing this condition in specific scenarios. The factors leading to errors in their cognitive processes, however, have received little attention. METHODS: Using a qualitative approach, we conducted in-depth semi-structured interviews with EPs in the emergency departments (EDs) of three hospitals in Taiwan. We purposively selected participants to obtain a sample that can contribute essential information about the diagnostic process. Sampling continued until new information was no longer being gathered. All interviews were audio-recorded, transcribed verbatim, and then analyzed by two investigators according to grounded theory. RESULTS: Based on 23 cases from 20 EPs, four themes emerged from the analysis regarding the reasons for diagnostic errors: (1) atypical disease presentations (6/23; 26%), (2) cognitive process of the physicians (21/23; 91%), (3) systemic factors (14/23; 61%), and (4) composite factors (14/23; 61%). CONCLUSIONS: These findings provide valuable insight into the factors that contribute to diagnostic error in cases of abdominal hollow organ perforation. The results offer a basis on which to build a framework for teaching physicians how to avoid misdiagnosing hollow organ perforation in the future.