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Introduction Previous studies have shown that risk attitudes and tolerance for uncertainty are significant factors in clinical decision-making, particularly in the practice of defensive medicine. These attributes have also been linked with rates of physician burnout. To date, the risk profile of emergency medicine (EM) physicians has not yet been described. Our goal was to examine the risk profile of EM residents using a widely available risk tolerance and attitude assessment tool. Methods First-, second-, and third-year residents of Thomas Jefferson University Hospital's EM residency program completed the commercially available, unmodified Risk Type Compass, a validated instrument offered by Multi-Health Systems (MHS Inc, New York, USA). Scored reports included information on residents' risk type (one of eight personality types that reflect their temperament and disposition); risk attitudes (domains where residents are more likely to engage in risky behaviors); and an overall risk tolerance indicator (RTi) (a numerical estimate of risk tolerance). RTi scores are reported as means with 95% confidence intervals (CIs). Results There was no significant change in RTi scores in residents across different years of their post-graduate year (PGY) training. PGY-one residents trended towards risk aversion; PGY-two residents were more risk-taking; and PGY-three residents scored in the middle. Conclusion Our pilot assessment of risk types in EM residents highlighted shifts across the years of training. Variations between members of each PGY cohort outweighed any outright differences between classes with regards to absolute risk tolerance. There was an increase in the frequency of health and safety risk-taking attitude with higher PGY class, and this was also the risk attitude that was the prominent domain for resident risk tolerance. The study was limited by sample size and single cross-sectional evaluation.
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Simulation has become a standard training method in emergency medicine (EM). Specifically, post-simulation debriefings offer participants the opportunity for reflection while exposing their knowledge and practice gaps. The educational yield of these debriefings, however, is contingent on the debriefer's skills. Without professional development, faculty and educators may not be equipped with supportive debriefing strategies. We propose the Six Thinking Hats (6TH), originally developed by Edward de Bono (1970) as a debriefing framework to support effective, high-yield debriefing conversations. The six colored hats represent six unique approaches to critical thinking. The white hat represents the facts; the green hat, creativity and next steps; the yellow hat, benefits/optimism; the red hat, emotions; the black hat, judgments; and the blue hat, facilitation. Four junior faculty members underwent a one-hour didactic and one-hour immersive workshop on the 6TH. Two simulation cases were randomly selected from archived simulation cases, which were used for the debriefing process. Each team consisted of one EM resident and one EM faculty. After each simulated case, the facilitator introduced the 6TH at the start of the debriefing, explaining the rules of engagement and the general sequence of hats to be used. Physical hats were worn by the facilitator at the beginning of the session and changed throughout stages of the debriefing, to remind participants of the type of thinking that was taking place at any given time. Participants who were provided with a colored hat prompt that physically described the type of thinking being employed throughout stages of the debriefing were better able to stay within that respective thinking frame during the discussion, compared to participants who were not provided this visual prompt. Participants of both simulation sessions agreed that the 6TH debriefing style was successful in creating a non-judgmental, comfortable environment that supported open discussion. The 6TH has the potential to be adopted as a debriefing framework, particularly for junior faculty members without extensive debriefing training. The 6TH is intuitive and has been marked by success in the organizational psychology literature. Faculty development on the 6TH will be essential if this framework is to be used as a debriefing model for educators in health care.
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Sporting event emergencies are common among both spectators and players, with unique sets of challenges associated with patient extrication in unfamiliar and chaotic environments. It is critical for sports physicians and trainers to deliberately train and prepare for emergent situations with limited resources during athletic events. One of the most difficult, yet commonly encountered challenges is determining when and how to safely remove an injured player's helmet and sporting equipment, particularly if a spinal injury is highly suspected. We created a high-fidelity simulation case to practice the safe extrication of a hockey player who collapses on the bench in the player's box, a space-restricted environment. The patient is a 25-year-old male hockey player who becomes unresponsive after a syncopal episode in the player's box, and subsequently transferred to a medical center for further evaluation. Critical actions include extrication of the player at the scene, diagnosis of syncope, placement of the unconscious player on a backboard with cervical-spine precautions, removal of the player's faceguard, removing the player off the ice, checking the electrocardiogram and glucose level, and transferring the player to a controlled environment. The learning objectives were to identify, evaluate, and manage the reversible causes of syncope, and demonstrate appropriate techniques for the optimal removal of sports equipment. Learner assessment was based on participation in the scenario and debriefing learners after the simulation. Post-simulation debriefing revealed that participants highly appreciated practicing not-so-commonly encountered hockey-related emergencies. Athletic trainers and emergency providers were able to effectively practice their management of the unresponsive hockey player. The participants were also able to deliberately practice their teamwork and communications skills with their peers. Learning points include proper c-spine immobilization techniques in a tight space and indication for gear-removal in an unconscious patient. As hockey continues to gain popularity, this simulation case will prepare athletic trainers and emergency providers to better address the reversible causes for syncope in hockey players, as well as safely and effectively extricate injured players from space-limiting sporting environments.
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Teamwork, a skill critical for quality patient care, is recognized as a core competency by the Accreditation Council for Graduate Medical Education (ACGME). To date, there is no consensus on how to effectively teach these skills in a forum that engages learners, immerses members in life-like activities, and builds both trust and rapport. Recreational 'Escape Rooms' have gained popularity in creating a life-like environment that rewards players for working together, solving puzzles, and completing successions of mind-bending tasks in order to effectively 'escape the room' in the time allotted. In this regard, escape rooms share many parallels with the multitasking and teamwork that is essential for a successful emergency department (ED) shift. A pilot group of nine emergency medicine (EM) residents and one senior EM faculty member underwent a commercial escape room as part of a team-building exercise in January 2018. The escape room required participants to practice teamwork, communication, task delegation, and critical thinking to tackle waves of increasingly complex puzzles, ranging from hidden objects, physical object assembly (i.e., jigsaw puzzles), and symbol matching. Activities required members to recognize and utilize the collective experiences, skills, knowledge base, and physical abilities of the group. After the game, players underwent a structured 'game-master' debriefing facilitated by an employee of the commercial escape room; this was followed by a post-event survey facilitated by a faculty member, which focused on participants' feelings, experiences, and problem-solving techniques. Escape rooms afford learners the opportunity to engage in an activity that rewards teamwork and effective leadership through experiences that directly link to specific ACGME milestones and educational learning theories. EM participants were engaged in the activity and felt that the escape room reproduced an environment analogous to the ED. The debriefing that followed the activity provided a satisfactory conclusion to the experience; but learners preferred a more organized debriefing format that provided them with constructive and specific feedback on their performance.
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As students in the health professions transition from the classroom into the clinical environment, they will be expected to effectively communicate with their team members and their patients. Effective communication skills are essential to their ability to effectively contribute to their clinical team and the patient care they deliver. The authors propose an interactive workshop that can support students' deliberate practice of communication skills. The authors designed a simulation workshop that affords students the opportunity to practice their communication and peer-to-peer coaching skills. Using LEGOs, a one-hour workshop was conducted with medical students. Students were divided into groups of two. Each student took on a different role: teacher or builder. Teachers were tasked with instructing builders on how to construct a pre-made LEGO structure, not allowing builders to look at the structure. A group debriefing followed to evaluate the activity and explore the themes that emerged. Twenty first-year medical students and 25 fourth-year medical students participated in this activity. Most groups were successful in reproducing the pre-made structure. Groups that pre-briefed before building were most successful. Unsuccessful groups did not define orientation or direction in mutually understood terms, resulting in the creation of an incorrect mirror image of the structure - a common phenomenon seen during the teaching of procedures in the clinical learning environment. The workshop was well received. Students made requests to have similar sessions throughout their training to better support the development of effective communication skills. The workshop can easily be applied to other specialties to assist with procedural skills instruction or in workshops focusing on effective communication.
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A 42-year-old man presented to the emergency department (ED) with newly diagnosed atrial fibrillation of unknown duration. Interrogation of the patient's wrist-worn activity tracker and smartphone application identified the onset of the arrhythmia as within the previous 3 hours, permitting electrocardioversion and discharge of the patient from the ED.