Can EMS providers and emergency department nurses work together to identify home risk factors for falls in older people?

Taiwan is an aging society and the ratio of falls among the older persons is high. Most falls occur at home, and multiple risk factors including home safety are involved. We propose a novel model of emergency medical technicians (EMTs) to assess home safety using scalable checklists. This study was conducted to evaluate its feasibility. This study was conducted between April 1, 2020 and March 31, 2021. The development of the risk factor assessment scale for falls in the home environment was divided into 2 stages. In stage 1, 2 researchers reviewed the extant literature. In stage 2, 6 experts judged the content validity index. According to EMT findings, emergency department (ED) nurses checked the items in the Checklist of Risk Factors for Falls in the Home Environment. The checklists were provided to the geriatric care manager (GCM) in the ED, who then discussed potential solutions with the patients or primary caregivers. A total of 235 participants were enrolled, and EMTs carried out environment assessment for 93.2% (219/235) of them. A total of 207 participants were at risk of falls at home and 79.7% (165/207) of them received intervention measures from the GCM according to the risk items. Education was the main intervention method, with 158 subjects. Moreover, seven subjects (4.2%, 7/165) were provided long-term care resources by the GCM with occupational therapists to help improve the environment at home. Our study provides an efficient method for EMTs to assess home fall hazards.

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.

Transient Atrioventricular Block as a Complication of Influenza A Virus: A Case Report.

Influenza is one of the most common respiratory viral infections, causing annual epidemics of respiratory illnesses characterized by sudden onset of fever, malaise, myalgias, cough, and other respiratory complaints. A spectrum of cardiovascular complications has also been reported in association with influenza infection. Cardiovascular involvement can occur through the direct effects of the virus on the myocardium or through the exacerbation of the existing cardiovascular disease. We report the case of an 86-year-old woman without a history of cardiac disease before admission who developed a transient complete atrioventricular block without myocarditis after acute infection with the influenza A virus.

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.

How experienced tutors facilitate tutorial dynamics in PBL groups.

BACKGROUND: Problem-based learning (PBL) tutorial are conducted in small groups, and successful learning in such groups requires good group facilitating skills. There is a lack of research on actual skills employed by tutors in facilitating the group dynamics. AIM: To explore the process of PBL tutorial small groups, focusing on the tutors' actual behavior in facilitating group dynamics. METHODS: Eight experienced tutors from various departments in medical colleges participated in this research. Forty tutorial group sessions were videotaped. Among the 636 tutorial intervention episodes, 142 of them were associated with facilitating group dynamics. Tutors interventions as well as their recalls were transcribed verbatim. Qualitative research methods were utilized to analyze the data. RESULTS: There were 10 tutorial group dynamic situations and 48 tutorial skills. Analysis of the tutors' intentions employing these skills in the 10 situations showed that tutors were trying to achieve the following aims: (1) iteration of PBL principles, (2) delegation of responsibility to the students, (3) creation of a good discussion forum, and (4) the generation of a good learning atmosphere. CONCLUSION: Results from this study provide PBL tutors with a practical frame of reference on group dynamic facilitating skills and stimulate further research on this topic.

Using personal qualities assessment to measure the moral orientation and personal qualities of medical students in a non-Western culture.

How to select candidates with appropriate personal qualities for medical school is an important issue. This study examined the psychometric properties and group differences of the Personal Qualities Assessment (PQA) to test the feasibility of using it as a tool to assess the medical school applicants in a non-Western culture. Seven hundred forty-six medical students in Taiwan completed two psychometric measures: Mojac to assess moral orientation and NACE to assess four aspects of interpersonal relationships. Thirty-one students completed the tests twice to establish test-retest reliability. A subsample of 127 students also completed a measure of the "Big Five" personality traits to examine the construct validity of these scales. Both Mojac and NACE had acceptable internal consistency and test-retest reliability. Conceptually, coherent and significant relationships were observed between test components and between the NACE and Big Five. NACE but not Mojac varied significantly between different sociodemographic groups. Both tests demonstrated acceptable psychometric properties. However, the predictive validity of PQA requires future studies.

Is medical students' moral orientation changeable after preclinical medical education?

PURPOSE: Moral orientation can affect ethical decision-making. Very few studies have focused on whether medical education can change the moral orientation of the students. The purpose of the present study was to document the types of moral orientation exhibited by medical students, and to study if their moral orientation was changed after preclinical education. METHODS: From 2007 to 2009, the Mojac scale was used to measure the moral orientation of Taiwan medical students. The students included 271 first-year and 109 third-year students. They were rated as a communitarian, dual, or libertarian group and followed for 2 years to monitor the changes in their Mojac scores. RESULTS: In both first and third-year students, the dual group after 2 years of preclinical medical education did not show any significant change. In the libertarian group, first and third-year students showed a statistically significant increase from a score of 99.4 and 101.3 to 103.0 and 105.7, respectively. In the communitarian group, first and third-year students showed a significant decline from 122.8 and 126.1 to 116.0 and 121.5, respectively. CONCLUSION: During the preclinical medical education years, students with communitarian orientation and libertarian orientation had changed in their moral orientation to become closer to dual orientation. These findings provide valuable hints to medical educators regarding bioethics education and the selection criteria of medical students for admission.

When a problem-based learning tutor decides to intervene.

PURPOSE: To appropriately contribute to group discussion, tutors should be experts in their field and possess facilitative skills. However, knowing when to interject is always a difficult question. This study investigated the specific scenarios or cues during group tutorial sessions that prompted or motivated tutors to interject and participate in the group discussion. METHOD: From 2005 through 2008, the authors, using the interpersonal process recall method, videotaped 40 tutorial discussions led by eight experienced tutors from the departments of medicine, nursing, and clinical psychology. The tutors were later shown the tapes and asked to explore their intentions and analyze the contexts for the 636 episodes in which they had intervened in the discussions. RESULTS: Qualitative analyses revealed three themes for the tutors' interventions: (1) Tutorial group process included 10 categories related to discussion sequence, students' roles, and group dynamics, (2) quality of discussion included nine categories related to clarity and accuracy of the information brought forward by the students, and relevance and critical appraisal of the information in relation to the major objectives, and (3) quality and quantity of the materials discussed included eight categories related to amount, datedness, accuracy, representativeness, and source (whether primary or secondary). CONCLUSIONS: These findings provide valuable insights into the contextual situations that lead problem-based learning tutors to intervene and provide material to build a framework for training new tutors.

Short-term outcomes of a near-full PBL curriculum in a new Taiwan medical school.

Problem-based learning (PBL), which incorporates principles of adult learning, is an important innovation in medical education. The use of PBL in health professional curricula is becoming more widespread. The curriculum design and the ways of implementing PBL are different among schools. More evidence is needed before a full PBL curriculum can be successfully implemented in an Asian medical school. Fu Jen Medical School is the first school in Taiwan to adopt a near-full PBL approach for the 3rd and 4th year curriculum (the medical education in Taiwan is mostly a 7-year undergraduate program). Fu Jen Medical School launched the interdisciplinary case-based, small group learning and integrated curriculum in 2002. This study investigated the short-term outcomes of this PBL curriculum, evaluated from several aspects. First, the self-directed learning readiness of the medical students before and after they entered the PBL curriculum was investigated using the Self-Directed Learning Readiness Scale (SDLRS). Second, semi-structured qualitative interviews were conducted with 5th and 6th year medical students and clinical instructors to understand the impact of PBL on the learning of clinical medicine. Finally, the passing rates in the Taiwan Medical Licensure Examination were compared with those of other medical schools in Taiwan. After 1 year of PBL, medical students at Fu Jen Medical School showed significant increases in the total SDLRS score, and in the subscores for learning strategy and self-assessment. These changes persisted until the end of 2 years of PBL. Students in their clinical years claimed that they were more active in learning, and had better learning skills and confidence in self-directed learning as compared with students from lecture-based curricula. PBL helps their clinical reasoning process, self-directed learning abilities and the use of knowledge in basic science to explain the clinical problem. On the other hand, the students thought that PBL had limited breadth and depth in clinical medicine and could not give them enough confidence in facing the national licensure examination. The initial batches of medical students (students from the first three cohorts) had the highest passing rate for Part 1 (basic sciences in medicine) and students from the first two cohorts had a 100% passing rate for Part 2 (clinical medicine) of the Taiwan Medical Licensure Examination. A near-full PBL curriculum in Asian medical schools is feasible and could encourage students to improve their self-directed learning abilities, learn adequate knowledge in basic sciences, and experience positive effects on learning clinical medicine. Better preparation of students for integrated learning of basic and clinical sciences are still needed, as is an emphasis on tutor training to improve the effectiveness of tutorial discussions.

Medical students' perception of good PBL tutors in Taiwan.

BACKGROUND: Problem-based learning (PBL) approach for medical education has been in use in Western countries for more than 30 years, but its use in Asian countries is quite recent. Because of cultural differences, the perception of a good tutor from the perspectives of students may be different. DESCRIPTION: Students from a PBL curriculum medical school at Fu-Jen Catholic University, Taiwan, were asked to provide a narrative evaluation of tutor performance from tutorial learning. Twenty-nine tutors and their 49 undergraduate students participated in the study from September 2002 to June 2003. EVALUATION: Qualitative methods were used to identify and code the tutors' behaviors. Students preferred tutors who (a) had knowledge in both basic and clinical science areas, (b) had appropriate facilitative tutorial skills, and (c) had positive personality traits. CONCLUSION: The results showed that students valued personality aspects of a tutor, an area that had been neglected in previous studies.