Introduction

A medical emergency is "A sudden medical event that requires immediate and appropriate treatment to control its impact and prevent further complications" (1). Medical students and interns frequently encounter critical emergencies in hospital settings, and they play a pivotal role in providing immediate care for patients facing life-threatening conditions or serious injuries. Their clinical learning in the emergency department is an essential part of their medical education, preparing them for these crucial responsibilities and being a necessary part of practicing medicine.

The current study focuses on medical students and interns across different cities in Saudi Arabia, during medical school and internship, the number of emergency medicine rotations varies among universities in Saudi Arabia, and not all Saudi universities yet offer independent emergency medicine courses, this leads to vast differences in the knowledge of graduating students (2). In addition, centers with North American emergency department models are becoming increasingly attractive for new graduate medical students, because of their optimal care, efficiency, and the presence of qualified senior staff which affects their quality of training across various institutions (3).

Good quality training depends on many factors including the knowledge and experience of supervisors, successful supervision, practical training and learning, and good health system (including good hospital management and efficient staff). On the other hand, bad quality of training will make the interns distrust supervisors and disrespect the health system (4).

Training in lifesaving skills, such as Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS), is vital for effective emergency care. Studies indicate that timely and accurate intervention can drastically improve patient outcomes, with research suggesting that up to 39% of deaths could be prevented with timely first aid (5). BLS is mandatory for interns, but most medical students were not BLS license holders (6).

Previous research in this field failed to identify gaps and areas requiring improvement and has often been limited in scope, with small sample sizes or narrow focuses, such as Cardiopulmonary resuscitation (CPR) or specific medical emergencies (e.g., stroke or Anaphylaxis) (7-9). A broader study across various universities is required to identify gaps and target areas. By surveying a larger, more diverse population, future research could focus on the most critical deficiencies in knowledge and confidence.

This study aims to assess the situation and identify gaps in training and areas for improvement. To our knowledge, no similar study has evaluated medical students' and interns' knowledge and confidence in handling medical emergencies. This study aims to assess the knowledge and confidence of Saudi medical students and interns in managing different medical emergencies.

Methods:

Study design

A cross-sectional study was conducted among interns and medical students of different regions in Saudi Arabia. The study used an online survey questionnaire among medical colleges, involving all Saudi interns and medical students from different academic years. The study was conducted from September to October 2024. Data was collected by using an electronically valid questionnaire in Google form that was made available to reach all students.

Sample size

The Raosoft sample size calculator was utilized to establish a suitable sample size for this cross-sectional study. The results, which encompass all Saudi medical students and interns, are statistically significant with a sample size of 665 drawn from a total population of 20,436 (5). This convenience sampling method was selected for its practicality and effectiveness in attracting a diverse group of participants.

Study Population and Technique

The sample was collected from Saudi medical students and interns across different regions in Saudi Arabia. The study used a nonprobability convenience sampling method that was conducted among medical students and interns in Saudi Arabia. The collected data was transferred to the Statistical Package for the Social Science (SPSS) program version 26 for statistical analysis. The participants' demographics such as age, gender, and location, were analyzed using descriptive statistics, Qualitative data variables presented as numbers and frequencies, and Quantitative data presented as mean±SD. A p-value <0.05 is considered statistical significance. The study includes only Saudi national medical students and interns who agreed to participate. Excluded from the study were non-Saudi nationals, students from other healthcare fields, and anyone who declined participation.

Survey Design and Pilot Study

The questionnaire was created based on the American Heart Association (AHA) guidelines for cardiac arrest (10), the Resuscitation Council UK guidelines for anaphylactic shock (11), and the National Institute for Clinical Excellence (NICE) guidelines for epilepsy (12) and trauma (13). The authors developed a standardized questionnaire in English, which was then validated by a panel of three expert academicians. Following this, the questionnaire was translated into Arabic using a forward and backward translation technique to ensure accuracy. The experts thoroughly reviewed the first draft of the questionnaire items in connection to the study objectives to determine their content validity across all domains (frequency and practice). This examination was carried out individually, with conversations undertaken to settle any disagreements until a consensus was reached. Suggested modifications were implemented to improve the questionnaire's validity, resulting in the final version being used in the study. The internal consistency of the questionnaire was evaluated using Cronbach's Alpha, yielding a coefficient of 0.70, indicating good reliability. A pilot study of 31 participants was done to collect comments on the questionnaire's transparency, simplicity, clarity, and comprehensibility. Although the pilot study responses were not included in the final analysis, they were thoroughly analyzed, resulting in changes that addressed difficulties with double-barreled, misleading, and leading questions. This iterative process culminated in the development of the finalized questionnaire.

Data Collection Tool

The first page of the survey contains the participant's informed consent, and the participant's nationality, if it’s Saudi, will move to the second page, which contains 16 questions divided into three main sections. The first section contains 6 biographic questions. The last two questions were closed-ended and asked the participants if they had previous experience with medical emergencies, such as internships and volunteer work. e.g., the second question asked if they were interested in emergency medicine as a future career. The second section contains 4 cases that assess the participant's knowledge and skills in handling medical emergencies. The cases were about cardiac arrest, anaphylactic shock, seizure management, and motor vehicle accidents (MVA). The third section contains 4 questions assessing the participants' attitudes towards medical emergencies, e.g. if they are confident in their ability to manage cardiac arrest situations.

Statistical analysis

The data were collected, reviewed, and then fed to SPSS version 26 (Released 2019. Armonk, NY: IBM Corp). All statistical methods used were two-tailed with an alpha level of 0.05, considering significance if the P value is less than or equal to 0.05. An overall knowledge score was computed by summing the correct answers where the correct answer was given a 1-point score and 0 was given otherwise. Students with a knowledge score below 50% of the total were categorized as having poor knowledge. Those scoring between 50% and 69% were classified as having fair knowledge, while students with scores of 70% or higher were considered to have good knowledge. Descriptive analysis for categorical data was done using frequencies and percentages, whereas numerical data (knowledge scores) were presented as mean with standard deviation. Also, participants' knowledge and awareness in handling medical emergencies and their attitude and confidence were tabulated while the overall knowledge level was graphed. Cross tabulation for showing factors associated with students' knowledge in handing medical emergencies and to assess relation between their knowledge and attitude using Pearson Chi-Square test and exact probability test for small frequency distributions. A multiple logistic regression model was used to assess the adjusted relations and predictors for the overall students' knowledge level based on the adjusted odds ratio and its 95% confidence interval.

Ethical considerations

The information gathered was kept confidential and used solely for scientific purposes, in line with ethical guidelines for research involving human subjects. The ethics committee of King Faisal University approved this study, referenced as (KFU-REC-2024-SEP-ETHICS2,557). Consent was obtained on the initial page, and participation in the study was completely voluntary. No personally identifiable information was included in the data analysis or publication. Ethical approval was gathered before the data collection process began.

Results

A total of 665 eligible medical students were included, 256 (38.5%) were from the western region, 145 (21.8%) from the central region, 139 (20.9%) from the eastern region, and 102 (15.3%) from the southern region but only 23 (3.5%) were from the northern region. Students' ages ranged from 18 to 30 years with a mean age of 22.3 ± 2.2 years old. A total of 434 (65.3%) were female students. As for the academic phase, 187 (28.1%) were in their pre-clinical years (2nd to 3rd), 329 (49.5%) were in their clinical tears (4th to 6th), and 149 (22.4%) were medical interns. Of 340 (51.1%) have previous experience with medical emergencies, and 284 (42.7%) are interested in Emergency Medicine as a future career (Table 1).

Table 1. Socio-demographic Characteristics of the Participants, Saudi Arabia (n=665)
Socio-demographics	No	%
Region
Central Region	145	21.8%
Northern Region	23	3.5%
Eastern Region	139	20.9%
Western Region	256	38.5%
Southern Region	102	15.3%
Age in years
18-20	154	23.2%
21-22	203	30.5%
23-25	216	32.5%
25+	92	13.8%
Mean ± SD	22.3 ± 2.2
Gender
Male	231	34.7%
Female	434	65.3%
Academic year
2nd year	79	11.9%
3rd year	108	16.2%
4th year	116	17.4%
5th year	100	15.0%
6th year	113	17.0%
Medical intern	149	22.4%
Academic phase
Pre-clinical years	187	28.1%
Clinical years	329	49.5%
Medical intern	149	22.4%
Do you have previous experience with medical emergencies?
Yes	340	51.1%
No	325	48.9%
Are you interested in Emergency medicine as a future career?
Yes	284	42.7%
No	381	57.3%

Table 2. Knowledge and Awareness of Medical Students and Interns Regarding Medical Emergencies, Saudi Arabia (n = 665)
Domain	Items		No	%
Cardiac Arrest	The first step you should take in a patient with cardiac arrest	Call for help and begin chest compressions	563	84.7%
		Check for a pulse again	21	3.2%
		Administer oxygen	40	6.0%
		Start an IV line	8	1.2%
		I don’t know	33	5.0%
	After initiating chest compressions, what is the recommended compression-to-ventilation ratio for adult CPR if you are alone?	30:2	449	67.5%
		15:1	59	8.9%
		5:1	19	2.9%
		20:2	21	3.2%
		I don’t know	117	17.6%
	What medication is commonly administered first during a cardiac arrest?	Epinephrine	389	58.5%
		Atropine	64	9.6%
		Lidocaine	29	4.4%
		Amiodarone	24	3.6%
		I don’t know	159	23.9%
Anaphylactic Shock	The first step you should take in a patient with anaphylactic shock	Administer epinephrine	395	59.4%
		Administer IV fluids	63	9.5%
		Provide antihistamines	97	14.6%
		Administer corticosteroids	30	4.5%
		I don’t know	80	12.0%
	How should epinephrine be administered in this scenario?	Intramuscularly	280	42.1%
		Intravenously	233	35.0%
		Subcutaneously	50	7.5%
		Orally	7	1.1%
		I don’t know	95	14.3%
	Which additional treatment should be considered after the initial management of anaphylaxis?	Observation in the emergency department for at least 4-6 hours	319	48.0%
		Discharge immediately if symptoms resolve	40	6.0%
		Continuous infusion of epinephrine	27	4.1%
		Initiate a second dose of epinephrine every 5 minutes until symptoms resolve	97	14.6%
		I don’t know	182	27.4%
Seizure Management	What is the priority in managing a seizure?	Protect the airway and ensure adequate breathing	420	63.2%
		Administer an anticonvulsant medication	77	11.6%
		Perform a CT scan of the head	52	7.8%
		I don’t know	116	17.4%
	If the patient experiences another seizure while in the emergency department, which medication should be administered first?	Benzodiazepines	322	48.4%
		Phenytoin	73	11.0%
		Levetiracetam	45	6.8%
		I don’t know	225	33.8%
	What is the most important consideration when monitoring a patient post-seizure?	Neurological status and airway management	363	54.6%
		Blood pressure monitoring	39	5.9%
		Checking blood glucose levels	65	9.8%
		Continuous EEG monitoring	59	8.9%
		I don’t know	139	20.9%
MVA	What is the initial management priority for MVA?	Stabilize the cervical spine and initiate fluid resuscitation	353	53.1%
		Obtain a detailed history and perform a full physical examination	55	8.3%
		Perform a focused assessment with sonography for trauma (FAST) scan	120	18.0%
		Administer pain relief medication	19	2.9%
		I don’t know	118	17.7%
	Which imaging modality is most appropriate initially if internal bleeding is suspected?	CT scan of the abdomen and pelvis	174	26.2%
		X-ray of the abdomen	55	8.3%
		MRI of the abdomen	41	6.2%
		Ultrasound of the abdomen	245	36.8%
		I don’t know	150	22.6%
	What is the recommended fluid resuscitation strategy for this patient?	Administer 1 liter of lactated Ringer's solution rapidly	112	16.8%
		Administer 500 ml of 0.9% saline bolus	152	22.9%
		Administer 1 liter of dextrose 5% in water	52	7.8%
		Administer 500 ml of hypertonic saline	29	4.4%
		I don’t know	320	48.1%

Table 3. The Knowledge and Awareness Scores for Different Emergency Domains Among Medical Students
Emergency Domain	Range	Mean	Standard Deviation	% of domain total	Knowledge level
Cardiac Arrest	0-3	2.11	0.97	70.2%	Good
Anaphylactic Shock	0-3	1.49	1.04	49.8%	Poor
Seizure Management	0-2	1.18	0.81	59.0%	Fair
MVA	0-3	0.96	0.78	32.0%	Poor
Overall knowledge score	0-11	5.79	2.64	52.6%	Fair

Good: ≥70%, Fair: 50–69%, Poor: <50%

Figure 1: The Overall Knowledge and Awareness of Medical Students and Interns in Handling Medical Emergencies, in Saudi Arabia (n = 665)

Table 4. The Attitude and Confidence of Medical Students and Interns in Handling Medical Emergencies in Saudi Arabia (n = 665)
Attitude	Strongly Disagree		Disagree		Neutral		Agree		Strongly Agree
	No	%	No	%	No	%	No	%	No	%
I feel confident in my ability to manage cardiac arrest situations.	137	20.6%	141	21.2%	204	30.7%	112	16.8%	71	10.7%
I am comfortable administering emergency medications under pressure.	142	21.4%	151	22.7%	215	32.3%	95	14.3%	62	9.3%
I believe hands-on training in medical emergencies is essential for all medical students.	47	7.1%	30	4.5%	86	12.9%	85	12.8%	417	62.7%
I am interested in receiving more training on how to handle medical emergencies.	58	8.7%	28	4.2%	86	12.9%	98	14.7%	395	59.4%

Table 5: Factors Associated with Medical Students' Knowledge of Handling Medical Emergencies. (n = 665)
Factors	Overall knowledge level				p-value
	Poor		Good
	No	%	No	%
Region					.949^
Central Region	93	64.1%	52	35.9%
Northern Region	15	65.2%	8	34.8%
Eastern Region	95	68.3%	44	31.7%
Western Region	166	64.8%	90	35.2%
Southern Region	68	66.7%	34	33.3%
Age in years					.001*
18-20	132	85.7%	22	14.3%
21-22	146	71.9%	57	28.1%
23-25	109	50.5%	107	49.5%
25+	50	54.3%	42	45.7%
Gender					.837
Male	153	66.2%	78	33.8%
Female	284	65.4%	150	34.6%
The academic phase					.001*
Pre-clinical years	160	85.6%	27	14.4%
Clinical years	208	63.2%	121	36.8%
Intern	69	46.3%	80	53.7%
Do you have previous experience with medical emergencies?					.001*
Yes	185	54.4%	155	45.6%
No	252	77.5%	73	22.5%
Are you interested in Emergency medicine as a future career?					.167
Yes	195	68.7%	89	31.3%
No	242	63.5%	139	36.5%

P: Pearson X2 test

^: Exact probability test

* P < 0.05 (significant)

Table 6. Relation Between Student's Knowledge about Handling Emergencies and their Attitude and Confidence (n=665)
Attitude	Overall knowledge level				p-value
	Poor		Good
	No	%	No	%
I feel confident in my ability to manage cardiac arrest situations.					.001*
Disagree	208	47.6%	70	30.7%
Neutral	126	28.8%	78	34.2%
Agree	103	23.6%	80	35.1%
I am comfortable administering emergency medications under pressure.					.536
Disagree	199	45.5%	94	41.2%
Neutral	136	31.1%	79	34.6%
Agree	102	23.3%	55	24.1%
I believe hands-on training in medical emergencies is essential for all medical students.					.001*^
Disagree	60	13.7%	17	7.5%
Neutral	69	15.8%	17	7.5%
Agree	308	70.5%	194	85.1%
I am interested in receiving more training on how to handle medical emergencies.					.002*^
Disagree	70	16.0%	16	7.0%
Neutral	60	13.7%	26	11.4%
Agree	307	70.3%	186	81.6%

P: Pearson X2 test

^: Exact probability test

* P < 0.05 (significant)

Table 7. Multiple Logistic Regression Model for Predictors of the Overall Students’ Knowledge Level about Handling Emergencies
Factors	P-value	ORA	95% CI
			Lower	Upper
Age in years	0.049*	1.27	1.0	1.63
Gender (female vs. male)	0.756	1.06	0.73	1.54
Academic phase (clinical vs pre-clinical)	0.002*	1.74	1.22	2.49
Have previous experience with medical emergencies	0.001*	2.03	1.37	2.99
Interest in Emergency medicine as a future career	0.303	1.21	0.84	1.75
Confidence in managing cardiac arrest	0.008*	1.28	1.07	1.53
Comfort with administering emergency medications under pressure	0.025*	0.81	0.68	0.97
Belief in essential role of hands-on emergency training	0.118	1.20	0.96	1.50
Interest in receiving more emergency training	0.102	1.20	0.96	1.49

ORA: Adjusted odds ratio

CI: Confidence interval

* P < 0.05 (significant)

Discussion

Interns and medical students must be well-trained in managing medical emergencies, regardless of their chosen specialty, as limited training time in the emergency department often leaves them unprepared to handle such situations. The present study found a low level of knowledge among medical students and interns; 228 (34.3%) students had good knowledge about emergencies versus 437 (65.7%) with poor knowledge levels. Also, the study found that students with previous experience with medical emergencies had an overall good knowledge level compared to those without experience. A similar result from a previous cross-sectional study by AlRabiah et al. conducted 2019 in Saudi Arabia assessed the knowledge, perception and exposure to emergency medicine of 356 medical students and found that the majority of participants had a low level of knowledge and students who took extracurricular courses, such as BLS, ACLS, Pediatrics Advanced Life Support (PALS), Advanced Trauma Life Support (ATLS) and all others, demonstrated a higher perception and knowledge of emergency medicine (2). Also, a 2020 cross-sectional study by Bhavsar et al. assessed the knowledge of emergency drugs among 282 medical interns and residents in India. The study identified knowledge gaps and found that interns and first-year residents had only an average understanding of medications used in emergency situations (14). This discrepancy between medical students, interns, and 1st-year residents is probably attributable to the level of education between them.

Another finding of the current study showed that only 27.5% of participants felt confident in managing cardiac arrest. This aligns with a 2012 cross-sectional study by Allen et al., which assessed the confidence of 99 medical interns in South African hospitals. While most interns reported confidence in performing general emergency procedures, they showed low confidence in performing CPR, defibrillation, diagnostic peritoneal lavage in adults, and intra-osseous line insertion in pediatric and neonatal patients (15). Also, in our study, only 23.6% are comfortable administering emergency medications under pressure. In contrast, a 2020 study by Bhavsar et al. conducted in India among 282 medical interns and residents found that most participants self-rated their knowledge of drugs used in emergency medical conditions as adequate (14). This discrepancy may be due to the different populations between the studies; medical interns and residents have more experience than students, which will increase confidence.

The current study determined the level of knowledge among medical students and interns in handling various medical emergencies. In cardiac arrest cases, 84.7% correctly reported calling for help and beginning chest compressions as the first step you should take in a patient with cardiac arrest, 67.5% know that 30:2 is the recommended compression-to-ventilation ratio for adult CPR alone, and 58.5% know that epinephrine is a medication commonly administered first during a cardiac arrest. Inconsistent with the previous studies that reported better knowledge in cardiac arrest management among interns and residents, 77% of interns and 86.6% of residents were knowledgeable regarding the CPR ratio. The majority, 85.1%, of interns and 86.7% of residents were found to be knowledgeable regarding adrenaline administration in cardiac arrest (14). This discrepancy may be due to years of experience and population differences between the studies. However, another study done in Southwestern Saudi Arabia found a potential gap in defibrillation training among family physicians in primary health care and found that one-fifth of the sample of family physicians would not attempt the use of an automated external defibrillator (AED) in case of emergencies (16). Similarly, a study conducted in India revealed that BLS knowledge among interns is very low, and regular BLS courses with frequent follow-up classes are necessary to improve knowledge and prevent knowledge attrition among them (17).

Regarding anaphylactic shock, 59.4% know that administration of epinephrine is the first step in treating a patient with anaphylactic shock, 42.1% know that epinephrine should be administered intramuscularly, and 48% reported that observation in the emergency department for at least 4-6 hours is the additional treatment that should be considered after the initial management of anaphylaxis. The current study reports better knowledge regarding drugs used in anaphylactic shock compared with the previous studies (14,18).

Regarding seizure management, 63.2% said that protecting the airway and ensuring adequate breathing is the priority in managing seizures, 48.4% reported Benzodiazepines as their first-choice medication if the patient experiences another seizure while in the emergency department, and 54.6% know that neurological status and airway management is the most crucial consideration when monitoring a patient post-seizure. Inconsistent with previous study showed that 86.5% of interns and 94% of residents were found to be knowledgeable about drugs used for status epilepticus (14). For MVA-related scenarios, 53.1% of participants correctly identified stabilizing the cervical spine and initiating fluid resuscitation as the initial management priority. Additionally, 26.2% recognized that a CT scan of the abdomen and pelvis is the appropriate initial step when internal bleeding is suspected, while 16.8% knew that rapid administration of 1 liter of lactated Ringer’s solution is the recommended fluid resuscitation strategy. Similar findings were reported in a cross-sectional study conducted in Nigeria by Amaraegbulam et al., which found that nonspecialist doctors involved in trauma care had limited knowledge of the ATLS protocol (19). In the current study, MVA had the lowest knowledge score in medical emergency cases, and this indicates that an ATLS training course may be needed to improve the knowledge, which aligns with a previous study (16).

Strengths and Limitations of the Study

This is the first study to assess the knowledge and confidence of medical students and interns in managing various medical emergencies across all medical schools in Saudi Arabia. It included a large, representative sample and used a validated questionnaire. However, the study did not evaluate practical BLS skills due to its questionnaire-based design. It also relied on self-reported data and covered a limited range of medical emergencies. Further research should assess actual clinical skills.

Area for future research

Further research is needed to identify gaps in emergency medicine training during medical school to improve knowledge and confidence among students and interns. It should also examine factors influencing confidence, as interns are often the first to respond to emergency cases in hospitals and must be prepared to manage them effectively.

Conclusion

This study offers a detailed assessment of Saudi medical students’ and interns’ knowledge and confidence in handling medical emergencies. Findings indicate inadequate preparedness, with notable gaps in key areas such as seizure management and motor vehicle accident response. These deficiencies suggest a need to strengthen emergency medicine training within medical curricula.

Declarations

Ethical approval and consent to participate

The research ethics committee at King Faisal University granted the authors permission to conduct the research. Approval number: (KFU-REC-2024-SEP-ETHICS2,557).

Consent for publication

All the participants provided informed consent for the results of the study to be published.

Data and materials accessibility

The corresponding author will provide the datasets used and/or analyzed in the present study upon reasonable request.

Competing interests

The authors have no conflicting interests to declare.

Funding

The authors have no funding to declare.

Acknowledgments

The authors thank all medical students and interns for their participation in the study. We also thank our supervisor for his support.