Building Bridges Between EMS and the ED

   As I was looking into opportunities for continuing medical education, a coworker informed me of an opportunity to collaborate with faculty at New York-Presbyterian Hospital's emergency medicine residency program. Dr. Fareed Nabiel Fareed, assistant professor of emergency medicine at the hospital, had asked if our department would be interested in participating in a new initiative to improve the teaching of trauma management to residents--specifically, to make it more hands-on by using volunteers to play trauma patients and moulage to simulate injuries.

   This new initiative reflects how simulation--initially adopted by healthcare from the airline industry--is becoming an increasingly important part of medical education. Rather than teaching about trauma in a lecture format, the idea is to emphasize the procedural aspects of directing a trauma resuscitation and the teamwork approach necessary to be successful. Paramedics, an integral part of that team, are invited to participate in these mock traumas because, just like in real trauma resuscitations, the interface and handoff between the paramedics bringing a critical trauma patient into the ED and the ED physicians receiving the patient is critical to excellent trauma care.

   These mock traumas allow our paramedics to earn CME credit from discussions held both before and after each scenario. In delineating our goals for these sessions, we saw the chance to take part in the debriefing and critique of the EM residents' abilities to perform skills that, as paramedics, we do every day in much less controlled environments--things like spinal immobilization, basic airway management, achieving rapid hemostasis and splinting fracture deformities. Learning how to obtain critical historical and prehospital data from EMS in the often-chaotic environment of a major trauma resuscitation is also emphasized. While the ED physicians learn more about the prehospital aspects of trauma care, EMS providers benefit by gaining insight into the continued care of their patients, from initial ED management and diagnostic testing to disposition and outcome. This insight helps paramedics focus on what prehospital information is most critical to relay to ED personnel.

   The majority of trauma cases simulated are actual cases that have presented to the New York-Presbyterian Hospital ED. Residents are given feedback on how their management compares to the actual management in the case, and are told what the outcome of the patient was (e.g., required a massive transfusion, went to the operating room, was managed nonoperatively, expired, etc.).

   One of our first mock trauma cases was a young male with abdominal evisceration secondary to a stab wound. The simulation involved a lot of makeup and preparation. To recreate the evisceration, we bought pig intestine skins from a local butcher. We then packed them with cornmeal, rice, beans and stewed tomatoes and bathed them in an emesis container with oil and blood-colored concentrate to mimic blood and clots. The patient (whom I played) was presented to the ED staff via EMS on a long board with cervical collar and a trauma dressing covering the evisceration. The ED staff were then expected to manage the patient as if it were a real scenario--that is, do the primary and secondary surveys, and address all the emergent issues (managing the airway and hypotension from intra-abdominal bleeding, detected via FAST exam; IV fluids; type and cross; blood transfusion; and surgery consultation for immediate transfer to the OR, etc.).

   Other cases we have recreated in our mock trauma sessions include multiple gunshot wounds requiring emergent thoracotomy, methamphetamine lab explosion victim, impaled screwdriver to the chest with pneumothorax, severe thermal burns with smoke inhalation and cyanide toxicity, five-story fall with multiple major injuries including an unstable pelvic fracture, and a critically ill pregnant woman in the third trimester in a motor vehicle collision requiring a perimortem cesarean section.