Resuscitation Rotation: A Novel Emergency Medicine Rotation to Augment Resuscitative Training

: Audience: This resuscitation curriculum is designed for second year emergency medicine residents who have completed their intensive care unit rotations during their first year of residency. Introduction: Resuscitation of critically ill patients is an integral part of emergency medicine (EM). While EM residents provide resuscitation during clinical training, dedicated educational time associated with resuscitations can vary. At our institution, we developed a new emergency department (ED) curriculum focused on improving and supplementing resident resuscitation training. Educational Goals : Our goal to augment resuscitative education in the ED in order to improve resident skill, confidence, and knowledge of resuscitative treatments.

1. Performing as team leader in a medical code 2. Performing as team leader in a trauma code 3. Describing post-cardiac arrest management, including implementation of targeted temperature management (TTM) 4. Determining indications and contraindications to TTM 5. Defining massive and sub-massive pulmonary embolism (PE) 6. Describing risk stratification of PE and active participation with discussion of adjunct therapies including thrombolytics 7. Describing and recognizing different cardiac arrhythmias (including, but not limited to, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, atrial fibrillation with rapid ventricular response, supraventricular tachycardia, nodal blocks, etc) 8. Recognizing septic patients and understanding the defining criteria 9. Understanding the indications to initial vasopressors on septic patients 10. Understanding how to perform various advanced airway techniques (including, but not limited to, endotracheal intubation via delayed and rapid sequence intubation, cricothyrotomy, etc) 11. Understanding how to perform and teach proper central line placement 12. Understanding how to perform and teach a thoracentesis 13. Understanding how to perform and teach intraosseous line placement 14. Understanding how to perform and teach proper thoracostomy tube placement 15. Understanding how to perform an emergent thoracotomy 16. On-shift teaching of junior residents and medical students with critical care procedures and helping ensure timely transitions of care USER GUIDE Burla  these are areas that can be improved upon. In order to improve emergency physician resuscitation training as a whole, we believe a more focused approach to resuscitation education in the ED is necessary.
Problem identification, general and targeted needs assessment: At our institution, we have a traditional ICU curriculum to supplement critical care training for first-and second-year residents. During clinical EM months, a section of our department is dedicated to high acuity patients, and residents receive a limited number of shifts in this area. Even with the ICU and high acuity EM shift exposure, we have noticed experiences between residents vary greatly, and augmenting their EM specific resuscitation education may be of benefit. This curriculum addresses the variation residents experience by dedicating time to resuscitative care in the ED, and to our knowledge, has not been described in previous literature.
Residents on this rotation will spend time specifically in our high acuity section of the ED, where they do not take over as the primary resident, but help facilitate the overall care and transition of these patients. Residents will also have the responsibility to provide dedicated longitudinal care of critically ill patients while in the ED. In addition, the critical care conferences allot time to review cases and relevant literature, allowing for further supplementation on uncommon clinical scenarios. This conference time is also an opportunity for debriefing and feedback in one to two-hour intervals, allowing for a more appropriately spaced learning environment. Overall, we believe that the curriculum is a contextual learning experience that motivates the residents and directly enhances patient care with the augmentation of their resuscitation experience.

Goals of the curriculum:
Our goal for this curriculum is to provide an educational model that focuses specifically on the care of the acutely ill in the ED and their transition of care.

Objectives of the curriculum:
Objectives: Resuscitation training and management During the rotation, learners should take part in active participation with procedures, medical decisions, and teaching in cases the learner is involved with. Goals should be discussed with the learners prior to the beginning of the rotation, which include how to monitor progress during the rotation and how the goals will be met. By the end of this rotation, learners should have developed more competency in the following: 1. Performing as team leader in a medical code 2. Performing as team leader in a trauma code 3. Describing post-cardiac arrest management, including implementation of targeted temperature management (TTM) 4. Determining indications and contraindications to TTM 5. Defining massive and sub-massive pulmonary embolism (PE) 6. Describing risk stratification of PE and active participation with discussion of adjunct therapies including thrombolytics 7. Describing and recognizing different cardiac arrhythmias (including, but not limited to, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, atrial fibrillation with rapid ventricular response, supraventricular tachycardia, nodal blocks, etc) 8. Recognizing septic patients and understanding the defining criteria 9. Understanding the indications to initial vasopressors on septic patients 10. Understanding how to perform various advanced airway techniques (including, but not limited to, endotracheal intubation via delayed and rapid sequence intubation, cricothyrotomy, etc) 11. Understanding how to perform and teach proper central line placement 12. Understanding how to perform and teach a thoracentesis 13. Understanding how to perform and teach intraosseous line placement 14. Understanding how to perform and teach proper thoracostomy tube placement 15. Understanding how to perform an emergent thoracotomy 16. On-shift teaching of junior residents and medical students with critical care procedures and helping ensure timely transitions of care Educational strategies: (See curriculum chart) Please refer to the curriculum chart of linked objectives and educational strategies.
Educational strategies, implementation of the rotation, and evaluation of the rotation were planned with a curriculum development approach 7 . This curriculum provides an adjunct to fulfilling the American College of Graduate Medical Education (ACGME) requirements for resident competencies regarding many patient care management and procedural skills 8 . Some of the main competencies are illustrated in section IV.A.5.a).
(2), which include: Since the majority of these skills are beyond the level of a firstyear resident, this rotation has been implemented in our residents' second-year core curriculum. Third-or fourth-year residents could also benefit from the rotation because the curriculum gives the opportunity to focus on supplementing any potential educational gaps. The best approach is to discuss goals with the resident prior to the rotation, identifying any areas of interest or skill deficiencies the resident may have. That way, if the resident isn't able to acquire enough experience in a given resuscitation skill or procedure, education can be supplemented during the critical care conferences and the resuscitation procedure session. For example, if a resident doesn't feel comfortable managing an unstable PE patient, and happens to not encounter one on a resuscitation shift, discussion at the conference can be centered around unstable PE management and literature review. In fact, during previous conferences, old cases from other residents' experiences were reviewed when relevant, which allowed for a natural dialogue about clinical experiences. In addition, the resuscitation procedure session serves a similar purpose: to practice rare resuscitative procedures in the simulation lab or with equipment designated for practice purposes in the ED.
While on shift, the resident will work in the critical care area, under the supervision of the faculty members in that specific area, or a resuscitation faculty member in the department. Aside from the critical care area, residents on this rotation will also survey the other areas of the ED for patients that have the potential to become unstable or require resuscitation. This patient population includes patients who are admitted to the hospital and boarded in the ED due to capacity. Patients being boarded in the ED have been a growing issue among hospitals across the nation 9 . Moreover, critically ill patients being boarded in the ED are a population that tends to have high mortality rates. 10, 11 One intent of this curriculum is for residents, while in training and after they graduate, to recognize when these patients will require early intervention.
The resuscitation resident also has a role to teach junior residents and medical students. This can occur in a variety of manners, including while on shift and during the weekly critical care conferences. Given that the resuscitation resident is usually unencumbered by other clinical care duties (seeing fewer acuity patients, primary ED note, etc), he or she has a little bit more time to teach effectively while on shift. During the conferences, the resident is expected to choose a relevant article to discuss. The resident will present this article to faculty members, junior residents, and medical students, with the purpose of teaching everyone the key points of the article, as well as determining whether the article would change their management of patients in the future.
The global concept of this rotation is to allow the resident as much ED resuscitation exposure as possible. The learners have a certain level of autonomy while on resuscitation shifts, with the ability to choose which articles they wish to present during the critical care conferences. At the beginning of the month, residents will receive the curriculum overview, description, required articles to read, instructions on patient logging, and a pre-rotation survey (all illustrated in appendices).

Associated content:
Curriculum content and overview will initially be presented to the resident in the form of an email before the rotation starts (Appendices A and B). The overview and description of the rotation in this email refers to department specific terminology. Examples of this include specific areas of the department and resources at our institution, such as a PE response team. The email includes the associated content illustrated below: • Curriculum Overview (Appendix A) Regarding encounters, a total of 363 logged resuscitation encounters were observed during the pilot period. While 10 residents were involved in the pilot period, only 7 residents were able to log their encounters. From these encounters, 148 resuscitation procedures were recorded (7 residents; >21 procedures per resident). These procedures included intubations, chest tubes, central lines, arterial lines, transvenous pacemaker placement, and various other procedures. All recorded data was voluntarily entered by each resident.
All data and feedback collected has had a positive influence on the rotation. An important aspect for successful implementation of this curriculum is to allow real time feedback while on the shift and anonymously through the post-rotation survey. This allows for in-the-moment adjustments during the month, as well as calculated changes to the curriculum over time. Encouraging residents at the beginning of the month to provide as much feedback as possible during the rotation can help streamline this process. Another tip for implementation is having faculty reinforce to the resuscitation resident that they are the adjunct provider, prior to the beginning of the rotation. This suggestion is to help prevent the resuscitation resident and other residents on shift from fighting over procedures and patient management. It is paramount that open communication occurs in any scenario where there are competing interests for a procedure. Moreover, during periarrest or cardiac arrest scenarios, it is important to task the resuscitation residents with pre-defining roles with the primary resident before taking ownership over any resuscitative procedure. Typically, this pre-defining discussion is about who initially manages the airway, who will be the team leader, and who will perform any secondary procedures such as central lines, arterial lines, etc. So far at our institution, this has not been an issue; however, if not addressed, we see the potential for conflict between the resuscitation resident and the residents on shift. One last suggestion for successful implementation is to assess how many faculty members would be willing to host the critical care conferences and on-shift experience because at least 2 would be the recommended minimum for adequate engagement. We had several faculty members demonstrate interest, and from the pilot period feedback, we concluded that this resuscitation curriculum was of benefit to our residents, and we incorporated it as a permanent rotation.

Evaluation and feedback:
As stated in the results and tips section, residents are given an opportunity to give feedback after their one-month rotation on an anonymous, password-protected electronic questionnaire. Within this questionnaire, feedback has resulted in improvements to the curriculum. One change that happened during the development of this rotation was to schedule the resuscitation resident at peak volume times during the day to get the most exposure to critically ill patients. Since there was no statistical difference in knowledge-based questions, core content material was added to the rotation readings and was made more of a focus during the critical care conferences. In addition, the conference time was increased to two hours in order to accommodate core content review, case review, and article presentation (illustrated in the core reading bullet-point attachment and further readings section). From feedback, it was also determined that the resuscitation resident should have a designated intradepartmental phone to utilize. This way, the resuscitation resident can be reached anywhere in the department and be notified of a critical ill patient. Feedback

Introduction
As you likely know, the goal of this rotation is to get great high acuity experience. Sometimes it is super busy in the high acuity area; other times you have to self-search for sick people in the other areas, and do not forget PEDS too!
• Whenever you are at work, notify all emergency medicine attendings and residents that you are around and carry a phone (ideally the resus phone).
• Your goal with this experience should be to get comfortable with the critical care decision tree and the utilization of aggressive adjuncts (ie, push dose pressors, awake intubations, rapid/safe placement of invasive lines, airway adjunct maneuvers, aggressive pulmonary embolism (PE) treatment, etc).
• A weekly resus meeting will occur to discuss cases that you were involved with and relevant literature.
• Resus Meeting duration is variable, usually ~ 1.5 hours at least. For each meeting we will discuss an article/resident.
• Resus-specific case logging is in New Innovations. This will not be part of your general procedure logging, but rather an additional log to track procedures during the rotation. Only log cases where you played a role in the care of the patient. • You may make your own hours (but please post in high acuity area doctor room).

DIDACTICS AND HANDS-ON CURRICULUM
• You should ideally work M/T/W/Th/Fri (minimum 8 hours per day, 40/week) or equivalent hours spread over 4-5 days.
• You can work with other resuscitation residents or separately (if applicable).
• Please keep resus faculty member apprised of resuscitation cases when he or she is in the department.
Resuscitation meetings • Weekly resus meetings will occur, with a total of 3-4 per month.
• You should have a list of the patients in whose resuscitations you participated during that week (keep stickers/Medical record numbers/etc).
• You should bring attention to cases which were either interesting or which you had any concerns regarding management.
• We will discuss articles (1 article per week/resident); please send article to the clerkship director ~ 48 hours or more prior to meeting.
• Make sure to keep updated on your normal procedure logs (log resuscitation cases in New Innovations).

Teaching
• When able, on shift teaching expectations with the PGY1 residents and medical students include: o Overseeing active bedside management o Supervising PGY1 critical care procedures o Improving patient flow for the department's high acuity patients.
• Assist in resident simulation sessions or procedure labs that are resuscitation pertinent during your month.

Research
• This rotation offers a great opportunity to start or enhance your scholarly activity.
• It is strongly encouraged to spend any downtime on this rotation participating in research activities, which will be discussed throughout the month.
• At rotations end it will be expected that you can describe your research participation during the month.
Reading material • All resuscitation required reading is available on New Innovations. o Delayed Sequence Intubation: A Prospective Observational Study (Weingart, et al).

Identification of patients to follow for "Resuscitation Rotation" purposes:
Pulmonary embolism • There is a PERT (PE Response Team) which for every PE, clerks activate a "PERT Consult" and a rapid response advanced practice provider (APP) responds. If the PE is sub-massive (ie, Intermediate Low Risk or Intermediate High Risk by European Society of Cardiology 2014 Guidelines) or massive category, then a multidisciplinary conference call occurs which is led by this same APP. When possible, jump on this conference call too since great learning! (The APP can provide you the call in #).
• When able, perform a bedside ultrasound (US) to assess for right ventricular (RV) heart strain, etc.
[if US team is around, they will perform it preferentially, evaluate/document cardiac/lungs and inferior vena cava (IVC) in qpath]. Obtaining this ED bedside US before a multidisciplinary • If patient is being considered for catheter-based adjunct PE treatment, ensure that patient can tolerate laying flat (the procedure can take an hour or more).

IF PATIENT CAN'T LIE FLAT NOTIFY THE APP OR PERT PHYSICIANS ON THE CALL.
• Screen for clinically significant large volume clot burden (saddle/etc).
• All high risk sub-massive PE and massive PE go to Cardiac Critical Care Unit (even if they do not receive an adjunct).
Unstable arrhythmia and cardiac arrest • Follow the process of arrhythmia treatment and resolution.
• Follow every unsuccessful and successful cardiac arrest.
• Run the code if no senior resident present.
• If not running code help facilitate IV access including intraosseous (IO) lines +/-intubation, help the team leader!
• Perform bedside US (if US team is around, they will perform it preferentially, evaluate/document cardiac/lungs and IVC in qpath).
• If return of spontaneous circulation (ROSC) is achieved, be involved in decision regarding targeted temperature management (TTM).
• If TTM is desired and approved by the ED attending on case, help get cold saline instilling/etc initially. The decision regarding TTM is at the discretion of the ED attending. IF PATIENT IS BEING COOLED, NOTIFY SINCE MAY BE STUDY ELIGIBLE.
• Ensure that EMS records are obtained. • Be aware of Surviving Sepsis recommendations; ensure compliance with the 3-& 6-hour bundles.

DIDACTICS AND HANDS-ON CURRICULUM
• In coordination with the EC attending/resident, facilitate line(s) placement if desired.
• Manage the initial fluid resuscitation and assess if patient is fluid responsive or not, reassess lactate level when possible in ED to gauge lactic acidemia clearance, ensure IV antibiotics are started as promptly as possible.
• Help determine if patient requires transition onto vasoactive agents and help make that decision in timely manner.
• Perform bedside US (if US team is around, they will perform it preferentially, evaluate/document cardiac/lungs and IVC in qpath). Serial bedside US IVC assessments are very helpful in this population to see how fluid responsive they are.
Neuro-deficit vs devastation • Facilitate getting patient immediately to CT (travel with patient, look at CT live time to see if any obvious findings).
• Perform stroke scale and tabulate results (compare to value the "stroke team" tabulates, address any major discrepancies).
• If ischemic cerebrovascular accident, help facilitate decisions with patient, stroke team, etc, regarding tissue plasminogen activator (tPA).
• If intracranial hemorrhage, help rapidly identify use of blood thinners and coordinate prompt use of reversal agents, as well as quickly determine from neurosurgery consultants what their BP goal is and if an arterial line is necessary.
• For all patients with major bleeding on a new oral anticoagulant (NOAC), consider FEIBA.
Miscellaneous skills to be attained/refined this month • When/how do I use push dose pressor?
• How do I perform a hemodynamically stable intubation?
• How do I perform an awake intubation?

Which of the following vasopressors may be best considered in conjunction with norepinephrine and what is the mechanism?
A. Dopamine, because it augments both stroke volume and endogenous norepinephrine

When choosing rate control for atrial fibrillation with rapid ventricular rate, which of the following is true?
A. Calcium channel blockers are first line for patients with congestive heart failure, acute coronary syndrome, or recent surgery B. Diltiazem has a faster onset of action than beta blockers and is therefore the first choice C. Cardioversion is contraindicated during pregnancy D. Verapamil is useful in patients with COPD but has more negative inotropic effects than diltiazem and may cause hypertension

The most useful laboratory test to check when a patient presents with bleeding associated with dabigatran is:
A. INR (international normalized ratio -if it is normal the patient is not adherent to their medication B. PTT (partial thromboplastin time)-typically it is significantly elevated on dabigatran and we can follow this serially to reliably assess drug clearance C. Creatine clearance -since dabigatran is highly renally cleared, acute kidney injury will prolong drug effects and clearance

Which of the following indication / tPA (tissue plasminogen activator) dosing is/are correct?
A. Acute ischemic stroke -0.9 mg/kg IV (max dose 90) with 10% given as bolus over 1 minute and the rest over 60 minutes B. Acute ischemic stroke -100 mg over 2 hours C. Acute pulmonary embolism -if weight is ≤67 kg: 15 mg IVP bolus over 1-2 minutes, THEN 0.75 mg/kg IV infusion over 30 minutes (not to exceed 50 mg), THEN 0.5 mg/kg IV over the next 60 minutes (not to exceed 35 mg over 1 hour). If weight is >67 kg: 15 mg IVP bolus over 1-2 minutes, THEN 50 mg IV infusion over next 30 minutes, THEN remaining 35 mg over next 60 minutes D. Acute myocardial infarction -0.9 mg/kg IV (max dose 90) with 10% given as bolus over 1 minute and the rest over 60 minutes E. Both