ABC | Volume 114, Nº1, January 2019

Original Article Aimoli & Miranda STEMI Management by Recently Graduated Physicians Arq Bras Cardiol. 2020; 114(1):35-44 The use of telemedicine can solve difficulties of ECG interpretation by newly graduated physicians, but this will be useless if they do not have enough knowledge on how to speed up the patient’s transfer according with the assistance flow established for each region. 15 Simulation has already been used to assess the performance of medical students in emergency scenarios, such as STEMI assistance in other countries. However, to our knowledge, no other Brazilian study has used a similar research method. The study showed that undergraduate students’ performance in treating simulated cases of STEMI are worse compared with other situations in which the patient is stable. For a total of 143 medical school fourth-year students, the total percentage of correct actions was 47.8% in the STEMI station, which was significantly lower in relation to the other stations (p<0.001). 16 This fact can be observed in practice, since during the undergraduate course they end up having more contact with stable patients, while more severe patients are treated by resident physicians. Thus, simulation is considered an interesting alternative for improving emergency competencies and abilities during the undergraduate course. 17 In an interesting study comparing simulation in small groups combined with traditional learning activities and traditional learning activities alone in 291 medical school fourth-year students for STEMI patients management, a significant improvement was observed in the performance of students in the simulation group (53.5 ± 8.9% vs. 47.4 ± 9.8%; p < 0.001), especially in relation to physical examination (48.5 ± 16.2% vs. 37.6 ± 13.1%; p < 0,02) and to diagnosis (75.7 ± 24.2% vs. 64.6 ± 25.1%; p < 0.02). 18 Another important aspect that should be emphasized with the undergraduate student is the improvement of communication skills. A small number of applicants (34%) showed effective communication with the patient concerning the disease and the recommended treatment. This issue is often neglected in emergency care, but it is a major stage, because the patient has a right to know what is happening and the treatment strategies proposed. Besides, access to information can decrease the level of anxiety and emotional tension during an acute episode. We highlight some limitations of this study. First, since only the applicants who were approved in the first phase of the selection process (written test) were submitted to practical evaluation, the presence of a selection bias should be considered. This may have overestimated the performance of the applicants in the selected sample and if the same evaluation had been applied to a general sample, probably the performance would have been lower than that observed. However, since in some less competitive specialties, almost all enrolled applicants were approved for the practical examination, this may have minimized this effect. Secondly, it was an evaluation applied in a single center (unicentric), but there were representatives from different regions of the country, although there was a predominance of the Southeast and Northeast regions, without an adequate sample distribution proportional to the number of graduates from different medical schools around the country. Therefore, their results cannot be extrapolated to all Brazilian territory. Thirdly, it was clarified that the fibrinolytic agent was not available in the service unit, as in the majority of these units in Brazil. Thus, immediate transfer to reperfusion therapy is indicated even in the absence of hospital beds. We agree that some differences can be observed according with the organization of the line of treatment for STEMI in each region of Brazil, like, for example, the availability of fibrinolytic agents in some of these Emergency Units. In such case, we suggest that the item Recognizes the need of immediate transfer for reperfusion therapy should be divided into two sub-items: administers the fibrinolytic agent and requests immediate transfer to a hospital, because either way, this patient will have to be transferred to a center capable of performing coronary intervention 19 and, in fact, no UPA in Brazil provides this resource. Fourth, the drug heparin was not included in the checklist. This fact occurred because, during initial care in a UPA the reperfusion strategy to be adopted for the patient (fibrinolytic therapy or primary angioplasty) is unknown and, depending on the strategy assigned, the type of heparin and the dosage prescribed as first option are different and, most of the times, this medication is delayed in order to be administered in the hospital service where the reperfusion therapy will be implemented. Although they integrate the treatment, the medications, beta blockers, statins and the angiotensin converting enzyme inhibitors, have not been included, because these drugs do not need to be prescribed immediately and can be introduced throughout the first twenty-four hours. Fifth, due to restricted time for each evaluation (5 minutes), the evaluators selected some topics that they considered more relevant, such as diagnosis and therapeutic treatment, at the expense of others related with clinical history and physical examination, which is understandable, since, most of the times, few alterations are observed in the physical examination of these patients. And, finally, this tool needs external validation in other training centers. Conclusion STEMI approach needs to be improved during medical undergraduate courses, highlighting practical aspects such as temporality for starting treatment and the assistance flows of these patients inside the Brazilian Unified Health System. Realistic simulation can be an adequate tool to improve these competencies. Author contributions Conception and design of the research, Acquisition of data, Analysis and interpretation of the data and Critical revision of the manuscript for intellectual content: Aimoli US, Miranda CH; Statistical analysis, Obtaining financing and Writing of the manuscript: Miranda CH. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. 42