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A course in emergency care for first-year medical students
CONCEPTS, COMPONENTS, AND CONFIGURATIONS
A Course in Emergency Care for First-Year Medical Students Michael McCally, MD, PhD Portland, Oregon Craig DeAtley, PA Thomas E. Piemme, MD Washington, DC
A 52-hour course in emergency medicine for first-year medical students was developed from the Department of Transportation's (DOT) training program for emergency medical technicians (EM'I'~ The objective of the course was to b'ain students to provide ire support and emergency care in the field at the level of competence of the EMT. Ninety-four percent of the first class mot these standards on written examination. Problems in the course included over-simplified presentations by paraprofessional faculty and an overemphasis on inhospital management by physician faculty. The program is well received by students and allows for introduction of clinical material into the first-year curriculum. The DOT training program for the EMT provides a useful model that, with slight adaptation, is appropriate for the first-year medical student. McCally M, DeAtley C, Piemme TE: A course in emergency care for first-year medical students. JACEP 7~>0-23, January, 1978. emergency care, courses, medical students.
INTRODUCTION In m a n y medical schools students often perceive the first-year p r o g r am to be disproportionately focused on the basic sciences to the exclusion of m a t e r i a l directly r e l e v a n t to clinical practice. In the last 20 years, n u m e r o u s ways have been explored to increase p a ti en t contact and clinical experience during the first year of medical school. 1 In 1976, The George Washington U n i v e r s i t y School of Medicine and H e a l t h Sciences introduced a 52-hou.r course in e m e r g e n c y care into the required c u r r i c u l u m of t h e first y e a r of medical school. The goal of the course was to provide medical students with clinical skills and information in e m e r g e n c y care t h r o u g h a comprehensive didactic and practical course. The course content and presentation is an adaptation of the 81-hour D e p a r t m e n t of T r a n s p o r t a t i o n (DOT) p r o g r a m for t r a i n i n g e m e r g e n c y medical t e c h n i c i a n s (EMTs). 2 On completion of the course and ari elective practicum, students are eligible to take the national certifying e x a m for EMTs (National Registry of E m e r g e n c y Medical Technicians, Columbus, Ohio).
COURSE DESCRIFrlON The first objective of the course was t h a t all freshmen medical students o b t a i n i n f o r m a t i o n and skills in e m e r g e n c y m e d i c i n e a d e q u a t e to provide e m e r g e n c y care and life support in the field. The level of competence was defined as t h a t of an EMT. The second objective was to offer students an opportuniFrom the Department of Health Care Sciences, The George Washington University School of Medicine and Health Sciences, Washington, DC.
7:1 (Jan) 1978
Address for reprints: Michael McCally, MD, PhD, Veterans Administration Hospital, Portland, Oregon 97207.
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ty to t rai n to a skill level to qualify t h e m for a state certifying e x a m i n a t i o n as an EMT. C o m p l e t i o n of a c e r t i f y i n g e x a m i n a t i o n was n o t a course r e q u i r e m e n t but our i n t e n t w as t h a t a n y m e d i c a l s t u d e n t be as competent as an EMT in renderi n g e m e r g e n c y c a r e in t h e field. A d d i t i o n a l o b j e c t i v e s m e t by t h e course were to introduce e m e r g e n c y m e d i c i n e as a m e d i c a l s p e c i a l t y and to familiarize medical students with the role of the E M T and other new h e a l t h professionals. The course is offered in the second semester of the first year in 18 weekly 3-hour sessions for a total of 52 hours. The content of the course is adapted from the DOT p r o g r a m (Table 1). As t h e s t u d e n t s had t a k e n a n a t o m y in t h e p r e v i o u s s e m e s t e r and were t a k i n g physiology simultaneously with e m e r g e n c y medicine, the basic science portion of the DOT c u r r i c u l u m was deleted. The r e m a i n ing m a t e r i a l was t a u g h t at a level appropriate to the first-year student. E m e r g e n c y m e d i c i n e s t a f f prepared l e a r n i n g obj'ectives and gave these to t h e p a r t i c i p a t i n g l e c tu r e r s for each session. A major effort was m a d e to a s s u r e t h a t t h e l e c t u r e s were at an appropriate level and that they dealt with r e c o g n i t i o n and m a n a g e m e n t of e m e r g e n c y problems in t h e f i e l d r a t h e r t h a n w i t h p a t h o p h y s i o l o g y or h o s p i t a l m a n agement. The t e x t used w a s Emergency
Care and Transportation of the Sick and Injured by the C o m m i t t e e on Inj u r i e s of the A m e r i c a n A c a d e m y of Orthopedic Surgeons. 8 For those w i s h i n g to qualify for a state EMT certifying e x a m i n a t i o n , a large portion of which is a d e m o n s t r a t io n of skills, a 3-hour " E m e r g e n c y Medicine P r a c t i c u m " was offered on an elective basis once a week. A requirem e n t of the elective was competence in basic life support t e c h n i q u e s as defined by r e c e n t A m e r i c a n H e a r t Association standards. 4 Three formats were used in the course: lecture, d e m o n s t r a t i o n and p r a c t i c u m (Table 1). Of the 52 req u i r e d hours, 30 w e r e lecture, te n p r a c t i c u m , six d e m o n s t r a t i o n , four examination, and two discussion and review. The d e m o n s t r a t i o n sessions were conducted by faculty and staff before the whole class and were supplemented by films and slide-tape shows (Table 2). T e n h o u r s of p r a c t i c u m t i m e were a v a i l a b l e for each s t u d e n t in the class of 150. Instructors in the p r a c t i c u m included p h y s i c i a n s and
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Table 1 COURSE CONTENT OF EMERGENCY MEDICINE: LECTURE, DEMONSTRATION AND PRACTICUM. Session 1
Format* a) Lecture b) Lecture c) Lecture/ Demonstration
2
3
a) Lecture b) Lecture c) a) b) c)
Demonstration Lecture Demonstration Practicum
Topic Course overview and pretest Emergency medicine: yesterday, today, and tomorrow Emergency physical assessment Cardiopulmonary failure Airway maintenance and mechanics of cardiopulmonary resuscitation Airways and resuscitation equipment Mechanical aids to breathing Cardiopulmonary resuscitation Cardiopulmonary resuscitation
4
a) Lecture b) Lecture c) Practicum
Emergency management of shock Emergency management of burns Cardiopulmonary resuscitation
5
a) Lectu re b) Practicum
Bleeding/Wounds Control of bleeding and bandaging
6
a) Lecture b) Lecture c) Demonstration
Injuries to upper extremity Injuries to lower extremity Splinting
7
a) Lecture b) Practicum
Injury to head and neck Splinting
8
a) Lecture b) Practicum
Extrication drags and carries Extrication drags and carries
9
a) Lecture/Film b) Practicum
Emergency childbirth Emergency childbirth
10
a) Lecture b) Lecture/ Demonstration c) Lecture
Electrical and environmental emergencies Case presentations
11
a) -b) Lecture c) Demonstration
Midterm examination Water safety Water safety
12
a) Lecture b) Lecture c) Lecture
The mentally disturbed patient Problems with pediatric patients Drug abuse emergencies
13
a) Lectu re
Venipunture, injections, and parenteral therapy Venipuncture, injections, and parenteral therapy
b) Practicum
Review
14
a) Lecture b) Lecture c) Lectu re
The unconscious patient Thoracic injury Abdominal injury
15
a) Lecture b) Lectu re c) Lectu re
Chest pain Neurologic emergencies Poisoning
16
a) Lecture b) Lecture c) Lecture
Pediatric emergencies Genitourinary emergencies Common emergencies
17
a) Lecture b) Discussion
Medico-legal issues in emergency medicine Review
18 a) - Final Examination *The total 52 hours were used as follows: Lecture - - 30, Demonstration - - 6, Practicum - - 10, Examinations - - 4, Discussion/Review-- 2
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n u r s i n g staff from the U n i v e r s i t y Hospital Emergency D e p a r t m e n t and paramedics from area rescue services and fire departments. For the whole class practicums, ten instructors, one per 15 students, were available. In the elective practicum course, one instructor was available for every four students. E q u i p m e n t and supplies needed for each group of five to ten students, and the approximate cost are shown (Table 3). O b v i o u s l y , one set of e q u i p m e n t a n d one i n s t r u c t o r are adequate for a n y size s t u d e n t body if small s t u d e n t groups are instructed in rotation. The n u m b e r s of sets of equipment required and the resulting initial dollar cost of the program depend on the n u m b e r of faculty and amount of t i m e a v a i l a b l e . S e v e r a l sets of e q u i p m e n t are required as a m i n i m u m and, i n c l u d i n g wages of EMT instructors for the practicum, the initial cost for a class of 150 students m a y be expected to be $6,000 to $10,000. Although the additional expense is significant, we believed t h a t the recording m a n i k i n (Recording Anne) is necessary for effective instruction in c a r d i o p u l m o n a r y r e s u s c i t a t i o n (CPR). With this device the s t u d e n t received i m m e d i a t e q u a n t i t a t i v e feedback and r e i n f o r c e m e n t on the adequacy of technique.
EVALUATION S t u d e n t performance was evaluated on three w r i t t e n exams: pretest, m i d t e r m a n d final. The written e x a m i n a t i o n s w e r e p r e p a r e d from a question pool s i m i l a r to those used in EMT e x a m i n a t i o n s i n Maryland and Virginia. The m e a n scores on the three exams for 150 students in percent right answers (+ 1 standard deviation) were 54 + 9, 87 + 6, and 82 + 6, r e s p e c t i v e l y . All b u t eight s t u d e n t s passed the r e q u i r e d course w i t h o u t remedial work. T h i r t y - e i g h t s t u d e n t s took the elective practicum. In addition to the written final, these s t u d e n t s were given a practical exam in which they were required to evaluate a n d treat victims with s i m u l a t e d injuries and raedical emergencies. All but two of these s t u d e n t s received certificates indicating successful completion of both the basic a n d p r a c t i c u m programs. The elective practicum is beiag offered again in 1977 to an additional 40 s t u d e n t s w i s h i n g the experience. S t u d e n t s completed a d e t a i l e d written e v a l u a t i o n of the program. Theil' principal criticism of the lec-
7:1 (Jan) 1978
Table 2 AUDIOVISUAL MATERIALS IN E M E R G E N C Y Type
Title
MEDICINE Source
1. Film
Emergency Childbirth
American College of Obstetrics and Gynecology One East Wacker Drive Chicago, Illinois 60601
2. Film
New Pulse of Life
American Heart Association Pyramid Films Box 1048 Santa Monica, California 90406
3. Slide Set Care and Transportation of the Sick and Injured
American Academy of Orthopaedic Surgeons 430 North Michigan Avenue Chicago, Illinois 60611
4. Film Strip Emergency Childbirth with cassette
American College of Surgeons' Committee on Trauma Oklahoma Trainex Corp. P.O. Box #116 Garden Grove, California 92642
5. Opaque
Emergency Care
6. Slides
Cardiopulmonary Resuscitation
Robert Brady Company 130 Que Street, N.W. Washington, D.C. 20002 Rocom - - Division of Hoffmann LaRoche, Inc. Nutley, New Jersey 07110
Table 3 SUPPLIES AND E Q U I P M E N T FOR TEACHING EMERGENCY MEDICINE
Reusable Equipment Resuscitation Manikins: Recording Adult (Resusci-Anne ®) Resusci-Baby Airway Set 1 Half-length Backboard RFB Bag Mask 1 Cervical Collar Esophageal Obturator 1 Plastic/Metal Carrying Case Set of Air Splints 1 Scissors Set of Padded Board Splints 1 Infusion Trainer Thomas Splint 1 BP Cuff and Stethoscope 1 Full-length Backboard 1 0 B Delivery Kit Disposable Equipment Penlights Injury Simulation Supply Dressing, Bandages, Tape Anne Replacement Parts (Tape, springs) IV and IM Equipment Miscellaneous ~tems Laryngoscope Intubation Model, Adult Intubation Model, Infant
t u r e s was t h a t some, p a r t i c u l a r l y t h o s e g i v e n by E M T s , were too simplistic and mechanical, while lectures given by physicians dealt too m u c h with pathologic m e c h a n i s m s a n d i n h o s p i t a l m a n a g e m e n t . The demonstrations appeared to be adeq u a t e a n d the p r a c t i c u m appropriate. The c o u r s e o r g a n i z a t i o n was well received in t h a t it required fun-
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Build-a-board 69X OB Manikin
d a m e n t a l skills and knowledge of all students a n d offered a n elective opp o r t u n i t y for those ( a p p r o x i m a t e l y one-half the class) desiring to further develop t h e i r skills. The f a c u l t y of t h e School of Medicine a n d H e a l t h Sciences and the C u r r i c u l u m C o m m i t t e e h a v e been satisfied and supportive. Our school is typical of m a n y in t h a t a
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m a j o r i t y of t h e p h y s i c i a n f a c u l t y have never had specific CPR training. DISCUSSION The course described represents a considerable i n v e s t m e n t of effort, time and money. However, after a year's experience, we are convinced of the value of t h e effort. Course objectives appear to have been m e t and s t u d e n t s h a v e r e a c h e d th e d e s i r e d level of competence. E v a l u a t i o n s and s t u d e n t critiques suggest t h a t they are prepared to deal effectively in the field with common emergencies. In a d d i t i o n , we h a v e s u p p o r t e d t h e A m e r i c a n C o l l e g e of E m e r g e n c y Physicians' (ACEP) and U n i v e r s i t y A s s o c i a t i o n for E m e r g e n c y Medicine's (UA/EM) recommendations on u n d e r g r a d u a t e m e d i c a l e d u c a tion by e s t a b l i s h i n g an E M T - l e v e l t r a i n i n g p r o g r a m as p a r t of o u r school's c u r r i c u l u m 2 F i n a l l y , students see this course as both r e l e v a n t and enjoyable. The m a t e r i a l clearly has u t i l i t y and affbrds s t u d e n t s an opportunity to see the cli~nical relevance of t h e i r an a t o m y and physiology studies. A l t h o u g h the importance of instruction in em er g e n c y medical care seems recognized, there is no recent information as to how this is being done in o u r m e d i c a l schools. Step h e n s o n 6 s u r v e y e d 106 m e d i c a l s c h o o l s a b o u t t h e i r t e a c h i n g of e m e r g e n c y m e d i c a l c a r e in 1970. M o n a g h a n and J o h n s o n 7 surveyed 12 schools in 1973 and concluded, as did Stephenson, t h a t t h e r e is g r e a t variation in the a m o u n t of time, y e a r of the instruction, teaching methods a n d r e q u i r e d or e l e c t i v e p r o g r a m m i n g in e m e r g e n c y care instruction. A review of the Association of American Medical Colleges 1975-76 C u r r i c u l u m Directory s r e v e a l s t h a t
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of 119 medical schools surveyed, ten offered a r e q u i r e d course in emerg e n c y m e d i c i n e , life s u p p o r t or f i r s t a i d in t h e f i r s t y e a r . T h e s e courses varied in l e n g t h from 6 to 44 hours, only one being more t h a n 22 hours. E i g h t y - e i g h t schools (75%) offered electives in emergency medicine. One o b j e c t i v e of o u r p r o g r a m w a s to a c q u a i n t m e d i c a l s t u d e n t s with the roles and skills of professional EMTs and other h e a l t h professionals. This was achieved by using E M T s , n u r s e s a n d f i r e m e n as instructors. The chief instructor (C.D.) is a physician's assistant and an EMT. Contrary to suggestions t h a t medical s t u d e n t s m a y feel t h e m s e l v e s too sophisticated to be t a u g h t by technicians or p a r a p r o f e s s i o n a l s , o u r experience has been t h a t first-year stud e n t s l e a r n w e l l f r o m E M T s and acknowledge t h ei r skills2 W a t k i n s et al 1° have described a course si m i l ar to ours designed specifically for the t r a i n i n g of EMTs. Their discussion of practical examination techniques and the use of vide o t a p e r e p l a y an d c r i t i q u e in the t e a c h i n g of car d i o p u l m o n ar y resuscir a t i o n skills is p a r t i c u l a r l y Useful and should be consulted by anyone developing this kind of program. We would propose t h a t a 52-hour course such as we h a v e described, m o d e l e d on t h e D O T p r o g r a m to t r a i n EMTs and offered to first-year m e d i c a l st u d en t s, m e e t s t h e object i v e s of p u b l i s h e d g u i d e l i n e s for teaching em er g en cy c a r e 2 J As with E M T s , m a j o r e m p h a s i s s h o u l d be placed on l e a r n i n g skills as opposed to the more typical stress on the presentation of information. The course is an appropriate introduction to a c o n t i n u u m of e x p e r i e n c e in e m e r gency medicine which at our school includes r e q u i r e d t h i r d - y e a r rotations t h r o u g h the e m e r g e n c y and anesthe-
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si a d e p a r t m e n t s a n d f o u r t h - y e a r electives in t r a u m a and e m e r g e n c y medicine.
REFERENCES 1. Hubbard WM Jr, Gronvall JA, DeMuth GR (eds.): The M e d i c a l S c h o o l Curriculum. Association of American Medical Colleges, Washington, DC, 1970. 2. Hubbard WM Jr, Gronvall JA, DeMuth GR (eds): The medical school curriculum. Association of American Medical Colleges. J Med Educ, November 1970, (part 2). 3. Basic Training Program for Emergency Medical Technician-Ambulance. US Department of T r a n s p o r t a t i o n . National Highway Safety Traffic Administration. Washington, DC, US Government Print. ing Office, 0-415-686, 1971. 4. Standards for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (EEC). J A M A 227(suppl):833-868, 1974. 5. Emergency Care and Transportation o[ the Sick and Injured. American Academy of Orthopaedic Surgeons, Committee on Injuries, Wisconsin, George Banto Co, Inc.
6. Recommended undergraduate medical school curriculum for life support skills. American College of Emergency Physicians and the University Association for Emergency Medical Services Position Paper. J A C E P 4:377, 1976. 7. Stephenson HE Jr: The teaching of emergency medical care in medical schools in the US and Canada. Bull Am Coll Surg 56:9-11, 1971. 8. Monaghan ED, Johnson G Jr: Guidelines for the education of medical students in emergency and medical services. J Med Educ 48:1124-1127, 1973. 9. Association of American Medical Colleges. 1975-1976 AAMC Curriculum Directory. Washington, DC. 10. Watkins GM, Metcalf GN, Audette LG: Emergency medical technician training in a medical school environment. J Trauma 15:772-778, 1975.
7:1 (Jan) 1978
A Course in Emergency Care for First-Year Medical Students Michael McCally, MD, PhD Portland, Oregon Craig DeAtley, PA Thomas E. Piemme, MD Washington, DC
A 52-hour course in emergency medicine for first-year medical students was developed from the Department of Transportation's (DOT) training program for emergency medical technicians (EM'I'~ The objective of the course was to b'ain students to provide ire support and emergency care in the field at the level of competence of the EMT. Ninety-four percent of the first class mot these standards on written examination. Problems in the course included over-simplified presentations by paraprofessional faculty and an overemphasis on inhospital management by physician faculty. The program is well received by students and allows for introduction of clinical material into the first-year curriculum. The DOT training program for the EMT provides a useful model that, with slight adaptation, is appropriate for the first-year medical student. McCally M, DeAtley C, Piemme TE: A course in emergency care for first-year medical students. JACEP 7~>0-23, January, 1978. emergency care, courses, medical students.
INTRODUCTION In m a n y medical schools students often perceive the first-year p r o g r am to be disproportionately focused on the basic sciences to the exclusion of m a t e r i a l directly r e l e v a n t to clinical practice. In the last 20 years, n u m e r o u s ways have been explored to increase p a ti en t contact and clinical experience during the first year of medical school. 1 In 1976, The George Washington U n i v e r s i t y School of Medicine and H e a l t h Sciences introduced a 52-hou.r course in e m e r g e n c y care into the required c u r r i c u l u m of t h e first y e a r of medical school. The goal of the course was to provide medical students with clinical skills and information in e m e r g e n c y care t h r o u g h a comprehensive didactic and practical course. The course content and presentation is an adaptation of the 81-hour D e p a r t m e n t of T r a n s p o r t a t i o n (DOT) p r o g r a m for t r a i n i n g e m e r g e n c y medical t e c h n i c i a n s (EMTs). 2 On completion of the course and ari elective practicum, students are eligible to take the national certifying e x a m for EMTs (National Registry of E m e r g e n c y Medical Technicians, Columbus, Ohio).
COURSE DESCRIFrlON The first objective of the course was t h a t all freshmen medical students o b t a i n i n f o r m a t i o n and skills in e m e r g e n c y m e d i c i n e a d e q u a t e to provide e m e r g e n c y care and life support in the field. The level of competence was defined as t h a t of an EMT. The second objective was to offer students an opportuniFrom the Department of Health Care Sciences, The George Washington University School of Medicine and Health Sciences, Washington, DC.
7:1 (Jan) 1978
Address for reprints: Michael McCally, MD, PhD, Veterans Administration Hospital, Portland, Oregon 97207.
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20/35
ty to t rai n to a skill level to qualify t h e m for a state certifying e x a m i n a t i o n as an EMT. C o m p l e t i o n of a c e r t i f y i n g e x a m i n a t i o n was n o t a course r e q u i r e m e n t but our i n t e n t w as t h a t a n y m e d i c a l s t u d e n t be as competent as an EMT in renderi n g e m e r g e n c y c a r e in t h e field. A d d i t i o n a l o b j e c t i v e s m e t by t h e course were to introduce e m e r g e n c y m e d i c i n e as a m e d i c a l s p e c i a l t y and to familiarize medical students with the role of the E M T and other new h e a l t h professionals. The course is offered in the second semester of the first year in 18 weekly 3-hour sessions for a total of 52 hours. The content of the course is adapted from the DOT p r o g r a m (Table 1). As t h e s t u d e n t s had t a k e n a n a t o m y in t h e p r e v i o u s s e m e s t e r and were t a k i n g physiology simultaneously with e m e r g e n c y medicine, the basic science portion of the DOT c u r r i c u l u m was deleted. The r e m a i n ing m a t e r i a l was t a u g h t at a level appropriate to the first-year student. E m e r g e n c y m e d i c i n e s t a f f prepared l e a r n i n g obj'ectives and gave these to t h e p a r t i c i p a t i n g l e c tu r e r s for each session. A major effort was m a d e to a s s u r e t h a t t h e l e c t u r e s were at an appropriate level and that they dealt with r e c o g n i t i o n and m a n a g e m e n t of e m e r g e n c y problems in t h e f i e l d r a t h e r t h a n w i t h p a t h o p h y s i o l o g y or h o s p i t a l m a n agement. The t e x t used w a s Emergency
Care and Transportation of the Sick and Injured by the C o m m i t t e e on Inj u r i e s of the A m e r i c a n A c a d e m y of Orthopedic Surgeons. 8 For those w i s h i n g to qualify for a state EMT certifying e x a m i n a t i o n , a large portion of which is a d e m o n s t r a t io n of skills, a 3-hour " E m e r g e n c y Medicine P r a c t i c u m " was offered on an elective basis once a week. A requirem e n t of the elective was competence in basic life support t e c h n i q u e s as defined by r e c e n t A m e r i c a n H e a r t Association standards. 4 Three formats were used in the course: lecture, d e m o n s t r a t i o n and p r a c t i c u m (Table 1). Of the 52 req u i r e d hours, 30 w e r e lecture, te n p r a c t i c u m , six d e m o n s t r a t i o n , four examination, and two discussion and review. The d e m o n s t r a t i o n sessions were conducted by faculty and staff before the whole class and were supplemented by films and slide-tape shows (Table 2). T e n h o u r s of p r a c t i c u m t i m e were a v a i l a b l e for each s t u d e n t in the class of 150. Instructors in the p r a c t i c u m included p h y s i c i a n s and
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Table 1 COURSE CONTENT OF EMERGENCY MEDICINE: LECTURE, DEMONSTRATION AND PRACTICUM. Session 1
Format* a) Lecture b) Lecture c) Lecture/ Demonstration
2
3
a) Lecture b) Lecture c) a) b) c)
Demonstration Lecture Demonstration Practicum
Topic Course overview and pretest Emergency medicine: yesterday, today, and tomorrow Emergency physical assessment Cardiopulmonary failure Airway maintenance and mechanics of cardiopulmonary resuscitation Airways and resuscitation equipment Mechanical aids to breathing Cardiopulmonary resuscitation Cardiopulmonary resuscitation
4
a) Lecture b) Lecture c) Practicum
Emergency management of shock Emergency management of burns Cardiopulmonary resuscitation
5
a) Lectu re b) Practicum
Bleeding/Wounds Control of bleeding and bandaging
6
a) Lecture b) Lecture c) Demonstration
Injuries to upper extremity Injuries to lower extremity Splinting
7
a) Lecture b) Practicum
Injury to head and neck Splinting
8
a) Lecture b) Practicum
Extrication drags and carries Extrication drags and carries
9
a) Lecture/Film b) Practicum
Emergency childbirth Emergency childbirth
10
a) Lecture b) Lecture/ Demonstration c) Lecture
Electrical and environmental emergencies Case presentations
11
a) -b) Lecture c) Demonstration
Midterm examination Water safety Water safety
12
a) Lecture b) Lecture c) Lecture
The mentally disturbed patient Problems with pediatric patients Drug abuse emergencies
13
a) Lectu re
Venipunture, injections, and parenteral therapy Venipuncture, injections, and parenteral therapy
b) Practicum
Review
14
a) Lecture b) Lecture c) Lectu re
The unconscious patient Thoracic injury Abdominal injury
15
a) Lecture b) Lectu re c) Lectu re
Chest pain Neurologic emergencies Poisoning
16
a) Lecture b) Lecture c) Lecture
Pediatric emergencies Genitourinary emergencies Common emergencies
17
a) Lecture b) Discussion
Medico-legal issues in emergency medicine Review
18 a) - Final Examination *The total 52 hours were used as follows: Lecture - - 30, Demonstration - - 6, Practicum - - 10, Examinations - - 4, Discussion/Review-- 2
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n u r s i n g staff from the U n i v e r s i t y Hospital Emergency D e p a r t m e n t and paramedics from area rescue services and fire departments. For the whole class practicums, ten instructors, one per 15 students, were available. In the elective practicum course, one instructor was available for every four students. E q u i p m e n t and supplies needed for each group of five to ten students, and the approximate cost are shown (Table 3). O b v i o u s l y , one set of e q u i p m e n t a n d one i n s t r u c t o r are adequate for a n y size s t u d e n t body if small s t u d e n t groups are instructed in rotation. The n u m b e r s of sets of equipment required and the resulting initial dollar cost of the program depend on the n u m b e r of faculty and amount of t i m e a v a i l a b l e . S e v e r a l sets of e q u i p m e n t are required as a m i n i m u m and, i n c l u d i n g wages of EMT instructors for the practicum, the initial cost for a class of 150 students m a y be expected to be $6,000 to $10,000. Although the additional expense is significant, we believed t h a t the recording m a n i k i n (Recording Anne) is necessary for effective instruction in c a r d i o p u l m o n a r y r e s u s c i t a t i o n (CPR). With this device the s t u d e n t received i m m e d i a t e q u a n t i t a t i v e feedback and r e i n f o r c e m e n t on the adequacy of technique.
EVALUATION S t u d e n t performance was evaluated on three w r i t t e n exams: pretest, m i d t e r m a n d final. The written e x a m i n a t i o n s w e r e p r e p a r e d from a question pool s i m i l a r to those used in EMT e x a m i n a t i o n s i n Maryland and Virginia. The m e a n scores on the three exams for 150 students in percent right answers (+ 1 standard deviation) were 54 + 9, 87 + 6, and 82 + 6, r e s p e c t i v e l y . All b u t eight s t u d e n t s passed the r e q u i r e d course w i t h o u t remedial work. T h i r t y - e i g h t s t u d e n t s took the elective practicum. In addition to the written final, these s t u d e n t s were given a practical exam in which they were required to evaluate a n d treat victims with s i m u l a t e d injuries and raedical emergencies. All but two of these s t u d e n t s received certificates indicating successful completion of both the basic a n d p r a c t i c u m programs. The elective practicum is beiag offered again in 1977 to an additional 40 s t u d e n t s w i s h i n g the experience. S t u d e n t s completed a d e t a i l e d written e v a l u a t i o n of the program. Theil' principal criticism of the lec-
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Table 2 AUDIOVISUAL MATERIALS IN E M E R G E N C Y Type
Title
MEDICINE Source
1. Film
Emergency Childbirth
American College of Obstetrics and Gynecology One East Wacker Drive Chicago, Illinois 60601
2. Film
New Pulse of Life
American Heart Association Pyramid Films Box 1048 Santa Monica, California 90406
3. Slide Set Care and Transportation of the Sick and Injured
American Academy of Orthopaedic Surgeons 430 North Michigan Avenue Chicago, Illinois 60611
4. Film Strip Emergency Childbirth with cassette
American College of Surgeons' Committee on Trauma Oklahoma Trainex Corp. P.O. Box #116 Garden Grove, California 92642
5. Opaque
Emergency Care
6. Slides
Cardiopulmonary Resuscitation
Robert Brady Company 130 Que Street, N.W. Washington, D.C. 20002 Rocom - - Division of Hoffmann LaRoche, Inc. Nutley, New Jersey 07110
Table 3 SUPPLIES AND E Q U I P M E N T FOR TEACHING EMERGENCY MEDICINE
Reusable Equipment Resuscitation Manikins: Recording Adult (Resusci-Anne ®) Resusci-Baby Airway Set 1 Half-length Backboard RFB Bag Mask 1 Cervical Collar Esophageal Obturator 1 Plastic/Metal Carrying Case Set of Air Splints 1 Scissors Set of Padded Board Splints 1 Infusion Trainer Thomas Splint 1 BP Cuff and Stethoscope 1 Full-length Backboard 1 0 B Delivery Kit Disposable Equipment Penlights Injury Simulation Supply Dressing, Bandages, Tape Anne Replacement Parts (Tape, springs) IV and IM Equipment Miscellaneous ~tems Laryngoscope Intubation Model, Adult Intubation Model, Infant
t u r e s was t h a t some, p a r t i c u l a r l y t h o s e g i v e n by E M T s , were too simplistic and mechanical, while lectures given by physicians dealt too m u c h with pathologic m e c h a n i s m s a n d i n h o s p i t a l m a n a g e m e n t . The demonstrations appeared to be adeq u a t e a n d the p r a c t i c u m appropriate. The c o u r s e o r g a n i z a t i o n was well received in t h a t it required fun-
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Build-a-board 69X OB Manikin
d a m e n t a l skills and knowledge of all students a n d offered a n elective opp o r t u n i t y for those ( a p p r o x i m a t e l y one-half the class) desiring to further develop t h e i r skills. The f a c u l t y of t h e School of Medicine a n d H e a l t h Sciences and the C u r r i c u l u m C o m m i t t e e h a v e been satisfied and supportive. Our school is typical of m a n y in t h a t a
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m a j o r i t y of t h e p h y s i c i a n f a c u l t y have never had specific CPR training. DISCUSSION The course described represents a considerable i n v e s t m e n t of effort, time and money. However, after a year's experience, we are convinced of the value of t h e effort. Course objectives appear to have been m e t and s t u d e n t s h a v e r e a c h e d th e d e s i r e d level of competence. E v a l u a t i o n s and s t u d e n t critiques suggest t h a t they are prepared to deal effectively in the field with common emergencies. In a d d i t i o n , we h a v e s u p p o r t e d t h e A m e r i c a n C o l l e g e of E m e r g e n c y Physicians' (ACEP) and U n i v e r s i t y A s s o c i a t i o n for E m e r g e n c y Medicine's (UA/EM) recommendations on u n d e r g r a d u a t e m e d i c a l e d u c a tion by e s t a b l i s h i n g an E M T - l e v e l t r a i n i n g p r o g r a m as p a r t of o u r school's c u r r i c u l u m 2 F i n a l l y , students see this course as both r e l e v a n t and enjoyable. The m a t e r i a l clearly has u t i l i t y and affbrds s t u d e n t s an opportunity to see the cli~nical relevance of t h e i r an a t o m y and physiology studies. A l t h o u g h the importance of instruction in em er g e n c y medical care seems recognized, there is no recent information as to how this is being done in o u r m e d i c a l schools. Step h e n s o n 6 s u r v e y e d 106 m e d i c a l s c h o o l s a b o u t t h e i r t e a c h i n g of e m e r g e n c y m e d i c a l c a r e in 1970. M o n a g h a n and J o h n s o n 7 surveyed 12 schools in 1973 and concluded, as did Stephenson, t h a t t h e r e is g r e a t variation in the a m o u n t of time, y e a r of the instruction, teaching methods a n d r e q u i r e d or e l e c t i v e p r o g r a m m i n g in e m e r g e n c y care instruction. A review of the Association of American Medical Colleges 1975-76 C u r r i c u l u m Directory s r e v e a l s t h a t
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of 119 medical schools surveyed, ten offered a r e q u i r e d course in emerg e n c y m e d i c i n e , life s u p p o r t or f i r s t a i d in t h e f i r s t y e a r . T h e s e courses varied in l e n g t h from 6 to 44 hours, only one being more t h a n 22 hours. E i g h t y - e i g h t schools (75%) offered electives in emergency medicine. One o b j e c t i v e of o u r p r o g r a m w a s to a c q u a i n t m e d i c a l s t u d e n t s with the roles and skills of professional EMTs and other h e a l t h professionals. This was achieved by using E M T s , n u r s e s a n d f i r e m e n as instructors. The chief instructor (C.D.) is a physician's assistant and an EMT. Contrary to suggestions t h a t medical s t u d e n t s m a y feel t h e m s e l v e s too sophisticated to be t a u g h t by technicians or p a r a p r o f e s s i o n a l s , o u r experience has been t h a t first-year stud e n t s l e a r n w e l l f r o m E M T s and acknowledge t h ei r skills2 W a t k i n s et al 1° have described a course si m i l ar to ours designed specifically for the t r a i n i n g of EMTs. Their discussion of practical examination techniques and the use of vide o t a p e r e p l a y an d c r i t i q u e in the t e a c h i n g of car d i o p u l m o n ar y resuscir a t i o n skills is p a r t i c u l a r l y Useful and should be consulted by anyone developing this kind of program. We would propose t h a t a 52-hour course such as we h a v e described, m o d e l e d on t h e D O T p r o g r a m to t r a i n EMTs and offered to first-year m e d i c a l st u d en t s, m e e t s t h e object i v e s of p u b l i s h e d g u i d e l i n e s for teaching em er g en cy c a r e 2 J As with E M T s , m a j o r e m p h a s i s s h o u l d be placed on l e a r n i n g skills as opposed to the more typical stress on the presentation of information. The course is an appropriate introduction to a c o n t i n u u m of e x p e r i e n c e in e m e r gency medicine which at our school includes r e q u i r e d t h i r d - y e a r rotations t h r o u g h the e m e r g e n c y and anesthe-
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si a d e p a r t m e n t s a n d f o u r t h - y e a r electives in t r a u m a and e m e r g e n c y medicine.
REFERENCES 1. Hubbard WM Jr, Gronvall JA, DeMuth GR (eds.): The M e d i c a l S c h o o l Curriculum. Association of American Medical Colleges, Washington, DC, 1970. 2. Hubbard WM Jr, Gronvall JA, DeMuth GR (eds): The medical school curriculum. Association of American Medical Colleges. J Med Educ, November 1970, (part 2). 3. Basic Training Program for Emergency Medical Technician-Ambulance. US Department of T r a n s p o r t a t i o n . National Highway Safety Traffic Administration. Washington, DC, US Government Print. ing Office, 0-415-686, 1971. 4. Standards for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (EEC). J A M A 227(suppl):833-868, 1974. 5. Emergency Care and Transportation o[ the Sick and Injured. American Academy of Orthopaedic Surgeons, Committee on Injuries, Wisconsin, George Banto Co, Inc.
6. Recommended undergraduate medical school curriculum for life support skills. American College of Emergency Physicians and the University Association for Emergency Medical Services Position Paper. J A C E P 4:377, 1976. 7. Stephenson HE Jr: The teaching of emergency medical care in medical schools in the US and Canada. Bull Am Coll Surg 56:9-11, 1971. 8. Monaghan ED, Johnson G Jr: Guidelines for the education of medical students in emergency and medical services. J Med Educ 48:1124-1127, 1973. 9. Association of American Medical Colleges. 1975-1976 AAMC Curriculum Directory. Washington, DC. 10. Watkins GM, Metcalf GN, Audette LG: Emergency medical technician training in a medical school environment. J Trauma 15:772-778, 1975.
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