SIMULATION A Simulated Scenario to Improve Communication Skills of Residents Providing Online Medical Command of Emergency Medical Service Providers

: Audience: The primary audience for this simulation exercise is emergency medicine (EM) residents. Additionally, this scenario may be adapted to provide education for any EM provider involved in providing pre-hospital, on-line medical command of emergency medical services (EMS). Introduction:


Topics:
Emergency medical services (EMS), pre-hospital medical command, pediatric advanced life support (PALS), pediatric critical care, airway management, weight-based dosing, pediatric medication dosing.

Objectives:
By the end of this session, the learner will be able to: 1. Discuss appropriate medical command instructions for pediatric cardiac arrest.part of the standard simulation curriculum.The scenario was written for implementation in a dedicated simulation center, where the instructor is not directly visible to the resident, but can contact the resident, via landline telephone in the simulation room, for on-line medical command.Alternatively, it can be implemented in a small group session, utilizing available telephones or cell phones, as long as the instructor is not directly visible to the resident, in order to maintain the functional realism of the EMS crew being in the field.The learner may have access to reference materials, including EMS protocols, smartphone-based applications that may have pediatric dosing calculations present, or any additional medical resource of their choosing.It may be necessary to guide the learner early in the scenario with prompts-such as, "we don't have access, and I can't get an IV on a kid this small" or "we don't have a Broselow tape, and I haven't worked on someone this small in a long time."This behavior will allow the learner to engage with the simulated phone call and support the functional realism of the scenario: although the learner is currently located in the simulation center, the learner is actively engaging with a stressed EMS provider who is acting as they typically would in a challenging patient scenario.
Learner reviews and feedback after completion of the scenario were largely positive, with learners commenting that the scenario enhanced their recall and understanding of prehospital protocols and increased comfort in providing on-line medical command via telephone during an anxiety-provoking clinical scenario.

References/suggestions for further reading:
1.

Background and brief information:
The learner receives a medical command call from a rural EMS crew on the scene of a 3-year-old female who was found submerged "face down" in a hot tub, and is now unresponsive and pulseless.The medic crew is inexperienced and is requesting guidance with the optimal way to proceed.If able to provide additional confederates, distraught parents can be heard in the background.

Initial presentation:
The patient is a 3-year-old female who was found face down in a hot tub.The parents believe that the patient may have been submerged for approximately ten minutes.At the time of the call to 911, the patient was unresponsive, parents were unable to detect a pulse, and 911 operators were able to instruct the family to start cardiopulmonary resuscitation (CPR).At the time of EMS arrival, CPR was in progress.EMS providers arrived 15 minutes after the initial 911 call and took over CPR.At the time of the call to medical command, EMS was ventilating with a bag valve mask device with 100% oxygen, in addition to performing high-quality CPR.How the scenario unfolds: The learner should begin to instruct the crew on the basic aspects of pediatric advanced life support (PALS), but will begin to meet challenges early in the case progression due to the crew's reported inexperience.The first hurdle arrives when the learner requests that epinephrine be administered, and the crew informs the learner that they do not have access.If instructed by the learner to gain intravenous access, attempts to obtain access will fail, and the learner should instruct them to obtain intraosseous (IO) access.
After obtaining IO access, the crew will state they do not have a current patient weight, and should be prompted to use a Broselow tape.As the case progresses and EMS is following the PALS algorithm with the assistance of the learner, the bagging effort will become difficult, with inconsistent chest rise and a poor pulse oximetry (pulse-ox) wave form.At this juncture, the learner should instruct EMS to perform an endotracheal intubation.The learner will be asked by EMS for guidance regarding endotracheal tube size and depth.The learner should instruct the EMS provider to use a 4.5 or 5.0 endotracheal tube and insert the tube to a depth of approximately 13.5cm.Learner should request end-tidal carbon dioxide (EtCO 2 ) monitoring, which the crew will then hook up.After the second dose of epinephrine, EtCO 2 will increase to 35mmHg, suggesting a possible return of spontaneous circulation (ROSC).The learner should request a pulse check, which will reveal ROSC with a sinus rate of 150, no spontaneous respirations, and BP of 80/60.If the learner does not recognize the increase in EtCO 2 as being suggestive of ROSC, the learner can be prompted to stop compressions for a rhythm check by the EMS provider requesting to do so.
The case will close with the learner being questioned by the EMS provider in regards to the most appropriate destination for definitive care of the patient.The learner should suggest transport via helicopter or critical care equipped ambulance to the nearest tertiary care children's hospital.o All specific queries regarding physical examination findings, with the exception of those mentioned in the primary survey, will be within normal limits.

Results:
Due to case a pre-hospital case, no lab work or imaging results are available for the learner(s).• When participating in the care of a pediatric cardiac arrest, be familiar with the appropriate management of a pediatric patient using the appropriate PALS algorithm for asystole.• In cases where peripheral IV access cannot be obtained immediately, an IO can be a rapid, efficient way to obtain access to provide critical resuscitation.• Although obtaining a definitive airway is certainly important, high quality chest compressions should not be interrupted in order to attempt intubation.• Obtaining an estimated weight and using a "peripheral brain" in the form of a Broselow tape, smart phone application, or alternative method-is a necessary step, prior to providing medications to a pediatric patient.• End-tidal CO 2 is a useful way to confirm endotracheal tube placement in the pre-hospital

OPERATOR MATERIALS
setting.An increase in end-tidal CO 2 during resuscitation can also represent ROSC.

Pearls for On-Line Medical Command Communication Skills
• Although it can be difficult, it is important to remain calm on the phone with the prehospital provider.Raising the voice, speaking harshly, critically, or providing overly critical feedback to the provider in the field will only serve to increase provider anxiety and lead to strained communication.• Becoming familiar with local EMS protocols for critical situations, including, but not limited to, pediatric cardiac arrest, is imperative.This will provide some familiarity with what equipment and medications are readily available to EMS providers in your region as well provide information regarding the scope of interventions that they may be comfortable with.• Consider the difficulties related to the setting and likely stressors for EMS as they are working to provide care to a critically ill child in a resource-poor, high-stakes setting with distraught family members immediately present.Provide supportive guidance, while also trying to limit asking for extraneous information from EMS, so that they can efficiently provide the directed interventions.
Other debriefing points: Start with a broad discussion of the difficulties of giving direction via telephone, as in this case.Suggested debriefing questions engaging the learners regarding the challenges of providing on-line medical command are outlined following this paragraph.Gradually transition to a discussion regarding the difficulties faced by the crew in this case and the challenges of EMS providers in general.This will help to build the learner's perspective and hopefully foster empathy and ease in future EMS interactions.Simulation educators utilizing this scenario should be aware that the high-stakes nature of this case surrounding a pediatric cardiac arrest may lead to strong emotional responses on the part of the learners.Educators should be mindful of this and allow time for learners to express their feelings during the initial reactions phase of the debriefing in order to allow the learners to process their reactions and ultimately engage with a discussion of the learning points and objectives.

DEBRIEFING AND EVALUATION PEARLS
Suggested debriefing questions: 1. What did you feel was difficult or challenging while you were directing the care of the EMS provider?2. Do you feel you received an adequate assessment from the EMS provider?What additional information might have been helpful initially about the patient or scene? 3. How would you provide feedback to the EMS provider and/or their medical director?4. What factors play a role in deciding the most appropriate method of transport and destination for this patient?Would ground transportation ever be an acceptable option?(Yes, when flight transportation is not safe due to weather or when the scene is in close proximity to an appropriate receiving facility, which in this case would be a tertiary care children's hospital.) 5. What safety concerns do you have for this crew/scene?6.What are the biggest differences between emergency medicine as practiced in the field and as practiced in the hospital?7.In situations such as this it is very likely the family would be incredibly upset; what are some strategies you can use to help them in this incredibly emotional situation?
Wrap Up: No specific additional wrap up information is recommended in this case.
Referencing and familiarity with the EMS protocol on pediatric cardiac arrest will be helpful for future management of similar cases by the learner.

Medical Command Simulation: Pediatric Cardiac Arrest Scenario
Learner: _________________________________________

Assessment Timeline
This timeline is to help observers assess their learners.It allows observer to make notes on when learners performed various tasks, which can help guide debriefing discussion.
2. Ask to obtain weight via Broselow tape.3. Order 1.5 mL (0.01 mg/kg) of 1:10,000 Epi every 3-5 minutes.(0.01 mg/kg to be given specifically in mL to ease communication with the EMS provider).4. Discuss intubation after being informed that BVM is failing, and instruct EMS to perform intubation without interruption in compressions.5. Appropriately determine endotracheal tube size: 4.5-5.0cm.Ask to obtain weight via Broselow tape.Order 1.5 mL (0.01 mg/kg) of 1:10,000 Epi every 3-5 minutes.(0.01 mg/kg to be given specifically in mL to ease communication with the EMS provider).
Discuss intubation after being informed that BVM is failing, and instruct EMS to perform intubation without interruption in compressions.
Appropriately determine endotracheal tube size:

2 .
Describe alternative methods to obtain weightbased dosing of pediatric critical care medications, if Broselow tape is unavailable.3. Identify need for a definitive airway in a pulseless patient without interruption of chest compressions.4. Identify need for rapid intraosseous access in a pulseless pediatric patient. 5. Describe the indications for helicopter transfer in a critically ill child.USER GUIDE Steratore A, et al.A Simulated Scenario to Improve Communication Skills of Residents Providing Online Medical Command of Emergency Medical Service Providers.JETem 2019.4(3):S49-67.https://doi.org/10.21980/J8SK8M52

Figure 1 .
Figure 1.West Virginia Office of Emergency Medical Services algorithm for resuscitation of pediatric asystolic arrest.

60 Medical Command Simulation: Pediatric Cardiac Arrest Scenario Patient Care Pearls
Steratore A, et al.A Simulated Scenario to Improve Communication Skills of Residents Providing Online Medical Command of Emergency Medical Service Providers.JETem 2019.4(3):S49-67.https://doi.org/10.21980/J8SK8M58SIMULATIONEVENTSTABLE:Iflearnerfails to suggest intubation, EMS will continue to state that BVM is becoming difficult.If the learner continues to fail to suggest intubation, EMS will state they don't feel they are ventilating the patient at all.OPERATOR MATERIALSSteratore A, et al.A Simulated Scenario to Improve Communication Skills of Residents Providing Online Medical Command of Emergency Medical Service Providers.JETem 2019.4(3):S49-67.https://doi.org/10.21980/J8SK8M59 Disposition: Transferred via helicopter to tertiary care children's hospital.DEBRIEFING AND EVALUATION PEARLS Steratore A, et al.A Simulated Scenario to Improve Communication Skills of Residents Providing Online Medical Command of Emergency Medical Service Providers.JETem 2019.4(3):S49-67.https://doi.org/10.21980/J8SK8M Standardized assessment form for simulation cases.JETem ã Developed by: Megan Osborn, MD, MHPE; Shannon Toohey, MD; Alisa Wray, MD Steratore A, et al.A Simulated Scenario to Improve Communication Skills of Residents Providing Online Medical Command of Emergency Medical Service Providers.JETem 2019.4(3):S49-67.https://doi.org/10.21980/J8SK8M65 Standardized assessment form for simulation cases.JETem ã Developed by: Megan Osborn, MD, MHPE; Shannon Toohey, MD; Alisa Wray, MD Steratore A, et al.A Simulated Scenario to Improve Communication Skills of Residents Providing Online Medical Command of Emergency Medical Service Providers.JETem 2019.4(3):S49-67.https://doi.org/10.21980/J8SK8MLearner: _________________________________________ Standardized assessment form for simulation cases.JETem ã Developed by: Megan Osborn, MD, MHPE; Shannon Toohey, MD; Alisa Wray, MD Steratore A, et al.A Simulated Scenario to Improve Communication Skills of Residents Providing Online Medical Command of Emergency Medical Service Providers.JETem 2019.4(3):S49-67.https://doi.org/10.21980/J8SK8M