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ORIGINAL ARTICLE
Year : 2022 | Volume
: 8
| Issue : 4 | Page : 213-216
Emergency medicine resident involvement in emergency medical services
Natalie C Akers, Bryan R Wilson, Adam M Ray
Department of Emergency Medicine, St. Luke's University Health Network, Pennsylvania, United States
Correspondence Address:
Dr. Adam M Ray
Department of Emergency Medicine, St. Luke's Bethlehem, 801 Ostrum St, Bethlehem, PA 18015
United States
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijam.ijam_116_21
Introduction: Emergency medical services (EMS) are a critical component to Emergency Medicine (EM) residency training. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) has established minimum training requirements for EM residency programs. Since the last study exploring resident EMS involvement was performed, there have been over 100 new EM resident programs started. Given the rapid increase in new EM programs, we sought to determine EMS experiences provided to current EM residents.
Materials and Methods: A 22-question anonymous online survey was distributed through E-mail to program directors of approved EM residencies in October 2020. A follow-up reminder was sent 3 weeks later.
Results: In total, 51 of 257 programs responded (20% response rate). Forty-five percent of EM residents experience between 10 and 25 EMS calls during their residency, 31% experience 26–50, and 20% experience >50 calls. The majority of programs (53%) have a separate EMS rotation where residents function as observers, 24% of residents function as providers, and 25% also have residents respond in a dedicated physician response vehicle. Aeromedical exposure is limited (47% have none and 43% average only 1–9 flights). Two-thirds of programs (67%) have residents provide online medical command during their ED shifts and 61% require residents to provide didactics to EMS clinicians. Despite ACGME requirements, only two-thirds of programs (69%) provide training about disaster/mass casualty incident (MCI) management and 67% have them participate in a disaster/MCI drill. About one-third of programs (31%) have decreased EMS experiences due to limited time in the residency curriculum, and 20% of programs have limited EMS experiences due to the COVID pandemic.
Conclusions: The majority of responding EM residency programs meet ACGME EMS-related requirements. There is an opportunity for improvement around disaster education based on these data. Limited time in the curriculum and the COVID pandemic were cited as reasons that programs have limited their EMS experiences.
The following core competencies are addressed in this article: Practice-Based Learning and Improvement, Medical Knowledge.
Keywords: Emergency medical services, emergency medicine, medical education
Emergency medical services (EMS) are an important part of the American Health-care system. In 2017, 14.5% of all patients seen in emergency departments (EDs) arrived by ambulance.[1] The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in emergency medicine (EM) require that residents must have “experience in EMS, emergency preparedness, and disaster management,” that “EMS experiences must include ground unit runs and should include direct medical oversight” and that resident experiences “should include participation in mass-casualty incident drills.”[2] Several proposed curricula for EMS training during residency have been published but there is no clear consensus on the best way to train EM residents in EMS.[3],[4],[5],[6],[7],[8],[9],[10] Since the last study,[11] exploring EM resident EMS involvement was conducted in 2010, over 100 new EM residencies have been started. Given the rapid increase in new EM programs, we sought to determine the EMS experiences provided to current EM residents in US EM residency programs.
MethodsThis was an anonymous survey of all ACGME-approved EM residencies in the United States. This study received approval from the Institutional Review Board. Utilizing the ACGME Institution and Program Finder public database (https://apps.acgme.org/ads/public/), all EM programs were identified. Programs that had not yet graduated a class of residents as of July 2020 were excluded. The authors reviewed each program to identify the programs director's (PD) E-mail, and for programs where no PD E-mail could be identified, the program coordinator's (PC) E-mail was collected. In the case that a PC was contacted, it was requested to have the survey forwarded to the PD. An E-mail was sent in October 2020 to 257 ACGME-approved US EM residency programs, which explained the purpose of the study and contained a weblink to complete an anonymous 22-question survey. A reminder E-mail was sent 3-week later. Survey questions included basic residency program demographic information (program length, geographic location, annual ED census, year of program start, program affiliation with a medical school, presence of an EMS fellowship, and employment model of faculty) as well as resident involvement in-ground and helicopter EMS, mass casualty incident (MCI) drills, medical command, educational experiences, Quality Improvement (QI)/Performance Improvement (PI) activities, and reasons for limiting EMS involvement. Descriptive statistics were calculated for each question. Due to a low response rate, no statistical methods to determine associations were utilized to prevent inserting unnecessary error.
ResultsIn total, 51 of 257 programs responded (19.8% response rate). An EMS fellowship is offered in 27.5% of these programs. [Table 1] and [Table 2] list the ground and aeromedical-based EMS activities. Most residents (45%) experience between 10 and 25 EMS calls during their residency, 31% experience 26–50, and 20% experience >50 calls. The majority of programs (53%) have a separate EMS rotation where residents function as observers; in 23.5% of programs residents function as providers. One-quarter of programs have residents respond in a dedicated physician response vehicle. Just over half (53%) of programs have aeromedical exposure for residents, but in the vast majority (81%) of those programs, the residents average only 1–9 flights during residency. Two-thirds of programs have residents provide routine online medical command during their ED shifts. Most programs (60.8%) require residents to provide didactics to EMS clinicians. Most programs (60.8%) do not utilize EM residents in EMS QI activities. Over two-thirds (68.6%) of programs provide training about disaster/MCI management and 66.7% have them participate in a disaster/MCI drill. Almost one-third (31%) of programs have decreased EMS experiences due to limited time in the residency curriculum, and over 20% of programs have limited EMS experiences due to the COVID-19 pandemic.
DiscussionAlthough EMS is a core part of EM practice, the experience residents get in EMS continues to be highly variable between programs. The Core Program Requirements have been updated to emphasize the importance of EMS education in residency training by requiring more EMS and disaster management experiences. With the advent of the EMS subspecialty in 2013 by American Board of Emergency Medicine (ABEM), the focus on formal training of EMS physicians has grown. As of January 2021, there were 830 ABEM-certified diplomates with a subspecialty certification in EMS, representing the largest subspecialty in EM.[12]
The ACGME Program Requirements for Graduate Medical Education in EM require that EM residents must have “experience in EMS, emergency preparedness, and disaster management,” that “EMS experiences must include ground unit runs and should include direct medical oversight” and that resident experiences “should include participation in mass-casualty incident drills.” The majority of responding programs meet these requirements.
All residents in responding programs participate in ground unit runs. EM residency programs are not permitted to require residents to participate in aeromedical activities, so it is not surprising that some programs do not have aeromedical involvement. However, despite being required by the ACGME, experiences in providing direct medical oversight, disaster management, and MCI drills are not universal. Providing direct medical oversight does not occur in 15.7% of responding programs, 17.7% do not include education about disaster management, and in one-third of programs, residents do not participate in mass-casualty incident drills. Since these activities are required by the ACGME, programs should add these activities to their residency curriculum.
Fulfilling these MCI requirements would not take considerable additional effort. Ambulance crews routinely call into receiving hospitals to obtain online medical direction from medical command physicians. Having EM residents complete a medical command course and serve as medical command physicians while working in the emergency department would be a simple way to rectify this deficiency. Many local EMS agencies have MCI training exercises which include both didactic training and practical field exercises. In addition, the Federal Aviation Administration requires that airports conduct an MCI simulation exercise every 3 years.[13] Residents could participate in these activities to gain the required MCI experiences and education.
There have been two prior surveys regarding EM resident EMS involvement: the first was done in 2005 by one of us[14], the second in 2010 by Katzer et al.[11] Those two studies asked similar, but not completely identical questions, and had higher response rates (Ray and Sole 66%, Katzer et al. 75%). While each of these surveys asked slightly different questions making exact comparisons impossible, there are some commonalities between the three. As with our survey, these surveys found that ground EMS involvement was the most common area of EMS involvement, while air-based EMS involvement was much less common. Providing direct medical oversight/medical command was also common.
Limitations
The low response rate makes it impossible to generalize the results of our survey to the larger group of all ACGME EM residencies. As the survey data was unable to be independently verified, self-reporting bias is a possibility. The likelihood of this is considered to be remote, however, as the surveys were anonymous and there seems to be no secondary gain from inaccurate reporting.
ConclusionsThe majority of responding EM residency programs meet EMS-related ACGME requirements. There is an opportunity for improvement around disaster education based on these data. Limited time in the residency curriculum and the COVID-19 pandemic has caused programs to limit their EMS experiences.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Research quality and ethics statement
The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this study was performed as a nonmandatory survey. It was reviewed by the St. Luke's University Health Network Institutional Review Board, found to be exempt, and the corresponding approval number is SLIR 2020-80.
References
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