Journal of Education and Teaching in Emergency Medicine

Audience: The targeted audience for this simulation is Emergency Medicine (EM) residents. Medicalstudents, advanced practice providers, and staff physicians could all also find educational merit in thisscenario.

Background: Cardiovascular disease is the leading cause of death in the United States according to the CDC.1Coronary artery disease caused 375,000 deaths 2021 alone, and about 5% of all adult patients have a priorhistory of coronary artery disease.2 Furthermore, chest pain itself is a common chief complaint encounteredin the ED, with nearly 8 million visits annually occurring throughout the United States, with 10-20% of thosepatients ultimately being diagnosed with an acute coronary syndrome3, including ST-elevation myocardialinfarction (STEMI). Given this, it is essential that EM residents are well prepared to care for all patientspresenting with chest pain, regardless of the acute care or emergency setting.Throughout their training, most EM residents typically learn and evaluate patients at a large tertiary orquaternary medical center with 24-hour catheterization laboratory availability. For patients presenting withelectrocardiogram (EKG) findings consistent with STEMI, the standard of care is for the patient to undergocardiac catheterization and stent placement within 90 minutes of arrival. Unfortunately, only half of patientsliving in rural areas have a cardiac catheterization-capable facility available to them within a 60-minutedriving radius, making it difficult for those patients to undergo cardiac catheterization within the desired timeframe.4 These patients remain candidates for thrombolytic therapy, but given infrequent opportunities tolearn about and deploy thrombolytic agents during residency training, graduating EM residents may beunfamiliar with indications, dosing, and contraindications before they begin practice. Furthermore, the recent EM workforce data suggests that although there may be an oversupply of 8,000 emergency physiciansby 2030, robust practice opportunities for emergency physicians remain in rural settings.5 Althoughhistorically EM graduates have not selected rural areas for practice, with only approximately 8% ofemergency physicians practicing in rural areas,6 it is likely that given the opportunities present and perceivedsaturation in many non-rural settings, more EM graduates will pursue practice in a rural setting. With thesechanging practice dynamics in mind, this simulation provides the opportunity for residents and medicalstudents to experience the management of a STEMI in the rural setting, with a focus upon the indications,contraindications, dosing, and disposition of a patient receiving thrombolytics.Educational Objectives: By the end of this simulation, learners will be able to:

1. Diagnose ST elevation myocardial infarction accurately and initiate thrombolysis in the rural settingwithout timely access to cardiac catheterization.2. Engage the simulated patient in a shared decision-making conversation, clearly outlying the benefitsand risks of thrombolysis.3. Identify the indications and contraindications for thrombolysis in ST elevation myocardial infarction.4. Arrange for transfer to a tertiary care center following completion of thrombolysis.

Educational Methods: This scenario is a simulated encounter in a rural emergency department settingrequiring the diagnosis of a STEMI, a discussion with the patient regarding the risks and benefits ofthrombolysis prior to administration, administration of thrombolysis, and transfer of patient to a higher levelof care.

Research Methods: The educational content of this simulation as a teaching instrument was evaluated bythe learner utilizing an internally developed survey after case completion. This survey was reviewed forprecision of language and assessment of learning objectives by our simulation faculty and other members ofour West Virginia University Emergency Medicine Department of Medical Education. The learner was askedto specify any prior experience with rural STEMI management as well as quantify via a five-point Likert Scale,where 1 = very uncomfortable and 5 = very comfortable, their level of comfort with thrombolysis before andafter the scenario as well as their comfort with having a shared decision-making conversation with patientswith regards to thrombolysis. Learners were also asked to rank the helpfulness of this simulation in preparingthem for administering thrombolytics for STEMI in a rural setting on a five-point Likert scale, where 1 = nothelpful and 5 =very helpful. An open response section was also provided to allow learners the opportunity tocomment directly on any aspect of the simulation.

Results: Data was collected anonymously from 16 PGY1-3 resident learners via surveys with a 100% responserate. Overall, the feedback received regarding the simulation was positive. There was a low average comfortlevel with administering thrombolytics and having a shared decision-making conversation regardingadministering thrombolytics. There was a high average rating of the helpfulness of this simulation in preparing residents for this conversation as well as managing STEMIs in a rural setting. Subjective commentsregarding the simulation were universally positive.

Discussion: The management of STEMI in the rural emergency department differs significantly from theenvironment in which many EM residents train. As a leading cause of death in the United States, STEMImanagement is a vital component of EM resident education. Although the concept of thrombolysis in the rural setting is discussed, the opportunity for real-world experience in its execution is often limited despitemany graduates ultimately working in rural emergency departments. This simulation sought to provide arealistic patient encounter to promote familiarity and comfort in the identification, patient discussion andexecution of thrombolysis in the treatment of a STEMI. The educational content was shown to be effectivevia learner survey completion.