AudienceThis case is targeted to emergency medicine residents of all levels. IntroductionUpper gastrointestinal bleeding (UGIB) is a common chief complaint encountered in the emergency department, ...resulting in over 500,000 hospitalizations and 20,000 deaths annually in the United States.1 The diagnosis and management of UGIB in stable patients is typically fairly straightforward. However, there are a number of circumstances where the treatment of UGIB is much more challenging, and emergency medicine (EM) physicians should be familiar with, and have experience managing, these difficult presentations. Massive UGIB can necessitate the need for management of a difficult airway in the setting of airway contamination, as well as placement of a gastroesophageal balloon tamponade device. The appropriate use and indications for performing this high-risk/low-frequency procedure requires dedicated practice. Furthermore, the management of gastrointestinal hemorrhage in a patient with a religious objection to the administration of blood products, including Jehovah's Witnesses, can be especially challenging and requires knowledge of alternative therapies to support blood pressure, oxygen carrying capacity, and decrease coagulopathy.2,3. Educational ObjectivesBy the end of this simulation, learners will be able to: 1) manage a hypotensive patient with syncope and hematemesis, 2) pharmacologically manage an acute UGIB addressing the various causes, 3) recognize worsening clinical status and intervene by performing difficult airway management, 4) place a gastroesophageal balloon tamponade device. Educational MethodsThis simulation was conducted with a high-fidelity mannequin with a separate medium-fidelity intubating mannequin that was modified to allow rapid filling of the oropharynx with simulated blood. Due to the COVID-19 pandemic, a total of six EM residents in various levels of training participated in the simulated patient encounter while the rest of the learners watched the simulation and participated in the debrief via video conference. Research MethodsFollowing the simulation and debrief session, all the residents, including those who participated in-person and via video conference, were sent a survey via surveymonkey.com to assess the educational quality of the simulation. ResultsOverall residents expressed positive feedback on the scenario, noting that the case was realistic, appropriately complex, and improved their medical knowledge and procedural skills. DiscussionThis case has a mixture of high-fidelity and medium-fidelity components which can be easily reproduced. The case was extremely useful in teaching EM residents of all levels not only how to manage large volume UGIB in a patient who is also a Jehovah's Witness, but also how to manage the airway and place a gastroesophageal balloon tamponade device. The case starts with a patient presenting with syncope and as the case unfolds, the patient's clinical status deteriorates, requiring learners to resuscitate, intubate, and obtain a gastroesophageal balloon tamponade.Residents commented that managing this case of an UGIB was extremely challenging because it exposed and filled important gaps in both their knowledge and procedural skills. Residents struggled most with identifying alternative therapies to blood products in patients with religious objections, and the step-by-step process of placing a Blakemore tube. TopicsUpper gastrointestinal bleed, hemorrhagic shock, Jehovah's Witness, difficult airway.
•A method for leveraging known physics, expressed in a PDE, to learn closures for missing physics.•Optimization of combined PDE-ML system with stochastic gradient descent, utilizing adjoint ...PDEs.•Complete demonstration for sub-filter-scale closure for large-eddy simulation (LES) of turbulence.•Outperforms common LES models.•Outperforms direct a priori learning of simple mismatch.
A framework is introduced that leverages known physics to reduce overfitting in machine learning for scientific applications. The partial differential equation (PDE) that expresses the physics is augmented with a neural network that uses available data to learn a description of the corresponding unknown or unrepresented physics. Training within this combined system corrects for missing, unknown, or erroneously represented physics, including discretization errors associated with the PDE's numerical solution. For optimization of the network within the PDE, an adjoint PDE is solved to provide high-dimensional gradients, and a stochastic adjoint method (SAM) further accelerates training. The approach is demonstrated for large-eddy simulation (LES) of turbulence. High-fidelity direct numerical simulations (DNS) of decaying isotropic turbulence provide the training data used to learn sub-filter-scale closures for the filtered Navier–Stokes equations. Out-of-sample comparisons show that the deep learning PDE method outperforms widely-used models, even for filter sizes so large that they become qualitatively incorrect. It also significantly outperforms the same neural network when a priori trained based on simple data mismatch, not accounting for the full PDE. Measures of discretization errors, which are well-known to be consequential in LES, point to the importance of the unified training formulation's design, which without modification corrects for them. For comparable accuracy, simulation runtime is significantly reduced. A relaxation of the typical discrete enforcement of the divergence-free constraint in the solver is also successful, instead allowing the DPM to approximately enforce incompressibility physics. Since the training loss function is not restricted to correspond directly to the closure to be learned, training can incorporate diverse data, including experimental data.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Syncope Due to a Ruptured Ectopic Pregnancy Hunt, Derek Jc; McLendon, Kevin; Conrad, Jodi
Journal of education & teaching in emergency medicine,
01/2022, Volume:
7, Issue:
1
Journal Article
Peer reviewed
Open access
AudienceThis simulation is intended for all levels of emergency medicine residents. IntroductionSyncope and near-syncope are very common presenting complaints to the emergency department.1 There are ...several causes of syncope ranging from benign to life threatening. It is imperative that the emergency physician is able to evaluate and treat patients with undifferentiated syncope even with limited information. Approximately half of syncope cases can be differentiated by the presentation and clinical context.1 In addition to a thorough history, an electrocardiogram (ECG) should be obtained on all patients presenting with syncope or near-syncope since it is non-invasive and cost effective in assessing cardiac causes of syncope. In this particular simulation, the cause of syncope is due to a hemorrhagic shock from a ruptured ectopic pregnancy. Educational ObjectivesAt the conclusion of this simulation, the learner will be able to:Review the initial management of syncopeUtilize laboratory and imaging techniques to diagnose a ruptured ectopic pregnancy.Demonstrate the ability to resuscitate and disposition an unstable ruptured ectopic pregnancy. Educational MethodsThis simulation case was designed as a medium-to-high fidelity simulation scenario. It could also be altered and utilized as a practice oral board exam case. Research MethodsThe quality of the simulation and educational content was evaluated by debriefing and verbal feedback that was obtained immediately after the case. Additionally, a survey was emailed to participants and observers of the case to provide qualitative feedback. ResultsPost-simulation feedback from learners and observers was positive. Everyone present for the simulation felt that it was realistic and provided a unique opportunity to practice resuscitation skills. DiscussionSyncope and near-syncope are common presentations to the emergency department with multiple etiologies that range from cardiac, neurologic, neurocardiogenic, and orthostatic to unknown. It is crucial that we diagnose and treat life-threatening causes of syncope rapidly and with limited information. In this case, the cause of syncope due to a ruptured ectopic pregnancy should be rapidly diagnosed with a thorough history and exam, urine pregnancy test, and a bedside abdominal ultrasound. Once the urine pregnancy test was resulted, ectopic pregnancy was the top differential diagnosis for each learner that participated. Initially, most learners only performed a transabdominal pelvic ultrasound of the pelvis, which is normal in the case. One learner performed a rapid ultrasound for shock and hypotension (RUSH) exam and was able to find free fluid in the right upper quadrant. Overall, this case and the debriefing topics were effective for learners at all levels. TopicsEctopic pregnancy, obstetrical emergencies, ultrasound, resuscitation.
AudienceThe target audience of this simulation is emergency medicine residents and medical students. The simulation is based on a real case of a 13-year-old female who presented with seizures and ...hypoxia and was ultimately diagnosed with pulmonary embolism. The case highlights diagnosis and management of an adolescent with new onset seizures, deterioration in status, and treatment options in pediatric cardiac arrest due to pulmonary embolism. BackgroundPulmonary embolism (PE) is an uncommon cause of hypoxia in children making diagnosis difficult. A study looking at 23 years of admission and autopsy data on children found the incidence of clinically significant pulmonary embolism to be 25 per 100,000.1 However, when children present to the emergency department with hypoxia and altered mental status, a diagnosis of pulmonary embolism cannot be excluded. Risk factors such as use of estrogen containing oral contraceptives, immobilization, and recent surgery should raise suspicion for pulmonary embolism in the clinically deteriorating adolescent patient.2,3. Educational ObjectivesBy the end of the simulation, learners will be able to:1) develop a differential diagnosis for an adolescent presenting with hypoxia and seizure-like activity2) discuss the utility of bedside ultrasound in helping to differentiate causes of hypoxia3) discuss management of cardiac arrest due to PE in the pediatric patientSecondary learning objectives include:4) discuss indications for emergent use of thrombolytics and Extracorporeal Membrane Oxygenation (ECMO) while becoming aware of institution-based limitations5) demonstrate interpersonal communication with family, nursing, pharmacy, and consultants during high stress situations. Educational MethodsThis is a high-fidelity simulation that allows learners to manage the diagnosis and treatment of pulmonary embolism in an adolescent patient. Participants participated in a debriefing after the simulation.Research Methods:The effectiveness of this case was evaluated by surveys given to learners after debriefing. Learners gave quantitative and qualitative results of their feedback using a 1-5 rating scale and leaving written feedback. This case was performed with residents in their first and second years of training. ResultsFeedback was overall positive, with many of the residents giving the case high scores on effectiveness of the simulation in their education. They enjoyed the case and reported they would feel more comfortable in a comparable situation in the future. DiscussionPulmonary embolism is an uncommon but important diagnosis for emergency medicine physicians to consider in pediatric cardiac arrest. This case has multiple parts and was based on a real case in our emergency department in which a patient presenting with new seizure-like activity followed by cardiac arrest was ultimately diagnosed with a PE. The case was well received by our learners who felt it improved their identification of this diagnosis and its management. TopicsPulmonary embolism, oral contraceptives, altered mental status, pediatric, adolescent, cardiac arrest, ECMO, thrombolytic, hypoxia, emergency medicine, medical simulation.
AudienceThis content can be used for trauma centers, emergency medicine residency programs, and emergency nursing. IntroductionMass casualty incidents (MCI) are becoming increasingly common and are ...occurring in locations that have not experienced them previously which adds to the challenge of readiness for emergency departments (EDs). Sporadic occurrences and limited resources add to the complexity of preparing for such an event. In advance of a large gathering in our metropolitan area, we developed and conducted a simulation to better prepare not only our residents, but our MCI planning committee, registered nurses (RNs) and emergency room technicians (ERTs) for an MCI.Emergency medicine is at the forefront of any hospital's response to an MCI. These events stretch the resources and force EDs to function differently than usual.1 Responding effectively is crucial to minimizing the morbidity and mortality of our patients while maximizing use of available resources. We can improve our level-headedness, efficiency, and department and hospital-level planning through simulation. This has particular implications for residency training with effects on education, preparedness, and wellness. Educational ObjectivesThe learners will (1) recognize state of mass casualty exercise as evidenced by verbalization or triaging by START (Simple Triage and Rapid Treatment) criteria, (2) triage several patients, including critically ill or peri-arrest acuities, according to START criteria, (3) recognize the need to limit care based on available resources, as evidenced by verbal orders or communication of priorities to team, and (4) limit emergency resuscitation, given limited resources, by only providing treatments and employing diagnostics that do not deplete limited time, staffing, and space inappropriately. Educational MethodsA small-scale, high-fidelity simulation was created to replicate the pace and acuity of patients presenting in an MCI. Three critically injured patients with multiple gunshot wounds, represented by high-fidelity manikins with moulaged wounds, were presented over a 6-minute span. The team was allowed 10 minutes total to conduct life-saving measures, targeted evaluation, and disposition of the patients. The simulation was then adapted for use in a second institution's simulation center to replicate and validate the objectives given a different system. Research MethodsThe learners were immediately verbally debriefed and feedback of the simulation, fidelity and appropriateness of the experience solicited. Unprompted, several of the learners volunteered that the efficacy of the experience was highly educational and valuable. Anonymized digital feedback was requested in the form of an online survey and was generally positive.The educational content was created by experts in simulation medicine and validated by content experts in the fields of Emergency Medicine, Trauma Surgery and Emergency Nursing. ResultsAfter the scenario ended, the learners were taken to a second room for debriefing by a trauma surgeon, an emergency medicine attending, and the nurse trauma educator. The actors were able to participate as secondary learners and were rotated out of simulation duties to participate in the debriefing. After this twenty-minute educational debrief, the learners were brought back to the simulation bay and were given a similar scenario. After this iteration, the team debriefed a second time. This hour schedule of cases and debrief was repeated a total of four times with a total of twelve individual learners. Suggestions and verbal feedback were noted for incorporation into appropriate committees or hospital departments. No formal assessment was done and inclusion was strictly on a voluntary basis. An evaluation of the session (on a Likert scale of 1-5) had six respondents which showed an average of 5 on how educational the session was, 4.8 on how realistic the session was, and 4.8 on how effective the session was. DiscussionSimulation allows participants to safely gain practical experience in MCI management. The experience was well-received, and the learners verbalized increased confidence should they encounter an MCI in the future. We developed this simulation to give residents and nurses first-hand experience performing under high-stress, resource-limited conditions. We also had other learners observing the process which allowed for productive debriefing and planning for improvement. The ideas generated from this ultimately became part of the hospital's MCI response plan. The main takeaways were triage strategy and limited resource management. TopicsMass casualty incident, mass gathering, penetrating trauma, high-fidelity simulation, team-based simulation, trauma center, hospital response planning.
Eclampsia Yang, Thomas J; Sangal, Rohit B; Conlon, Lauren W
Journal of education & teaching in emergency medicine,
07/2021, Volume:
6, Issue:
3
Journal Article
Peer reviewed
Open access
AudienceEmergency medicine residents. IntroductionEclampsia is the development of a generalized seizure in pregnant patients with hypertension of pregnancy.1 Eclampsia exists on the spectrum of ...hypertension-related disorders in pregnancy, occurs in 1 out of 1,000-10,000 deliveries,1-3and is associated with significant maternal and fetal morbidity and mortality.4 Given the emergent nature of eclampsia and the benefit of rapid treatment, emergency medicine (EM) physicians need to quickly recognize and treat this rare pathology. Although residents have three to four years before becoming an attending, not all emergent pathologies may present clinically during their training. It is important to simulate rare, treatable conditions such as eclampsia to give learners exposure confidence in managing this disease. Educational ObjectivesBy the end of this simulation session, learners will be able to:Demonstrate care of a gravid patient with altered mental statusDemonstrate care of a gravid patient with seizuresRecognize care involved in assessment of fetal statusExecute appropriate subspecialty consultationRecognize the clinical signs and symptoms of eclampsiaDistinguish different treatment options for eclampsiaIdentify magnesium toxicity and reversal agentDifferentiate the spectrum of preeclampsia. Educational MethodsAs an educational strategy, simulation allows learners to partake in experiential learning. By creating a safe and supportive learning environment, simulation allows learners to facilitate deliberate practice and transfer learning in debriefing sessions. High-fidelity sessions involve software and technology to mimic realistic patient environments, which also activate learners' affective states to aid in decision-making abilities in complex medical cases.This session was conducted using a high-fidelity mannequin, SimMom (Laerdal), and a controlling Laerdal LLEAP Software. Faculty-led debriefing followed the simulation case and included discussion regarding presentation, spectrum, and management of the obstetrical emergency.5. Research MethodsResident participants completed an evaluation form consisting of questions on a 5-point Likert scale assessing the realism and usefulness of the simulation. ResultsAll 18 residents who participated in the simulation completed an evaluation form, and all agreed or strongly agreed the case was realistic and useful. DiscussionIncorporating high-stakes, low-frequency presentations through simulation can be readily applied in residency education and well-received by residents. Increasing the difficulty through adjusting the clinical history and exam may challenge learners further. TopicsMedical simulation, eclampsia, pregnancy, obstetrics, emergency medicine.
Tracheoinnominate Artery Fistula Tarver, Emily M; Lerant, Anna A; Orledge, Jeffrey D ...
Journal of education & teaching in emergency medicine,
07/2021, Volume:
6, Issue:
3
Journal Article
Peer reviewed
Open access
AudienceThis simulation provides training for emergency medicine residents in the stepwise management of a patient who presents with bleeding from a tracheoinnominate artery fistula. Additional ...learners who might benefit from this simulation are otolaryngology and general surgery residents as well as critical care fellows. IntroductionHemorrhage from a tracheoinnominate artery fistula (TIAF) is a rare but life-threatening complication in a patient with a recent tracheostomy. This complication occurs in 0.7% of tracheostomy patients with a mortality of 50-70%.1 Seventy-five percent of patients with a TIAF will present within the first three weeks of surgery and 50% of patients will present with a sentinel bleed that briefly resolves.1 Key elements of a history and exam that should raise a provider's concern for this diagnosis include a recent tracheostomy (within the last 4 weeks), a percutaneous tracheostomy, prior radiation, chronic steroid use, a neck or chest deformity or a sentinel bleed.2 Survival from a TIAF hinges upon emergent, operative repair by an otolaryngologist and cardiothoracic surgeon. Cuff hyperinflation and the Utley Maneuver are critical bedside interventions to temporize this massive bleed and stabilize the patient for definitive, operative repair. Educational ObjectivesBy the end of this simulation, learners will be able to: 1) perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site, 2) describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF, 3) demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver, 4) verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above, 5) demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol. Educational MethodsThis case was written with a modified, low-fidelity manikin, traditionally used for training in nasogastric tube placement and tracheostomy care. We modified this manikin to simulate a hemorrhage from the tracheostomy site.3 The patient in our case had a history of laryngeal cancer, and thus we occluded his larynx for this simulation. As a result of this obstruction, he was unable to be intubated from above. We provided confederates, a bedside nurse and family member, to assist the learners throughout the case. We also utilized a simulation technician to operate dynamic vital signs on a simulated cardiac monitor. It would be technically challenging to adapt this case to a high-fidelity simulator due to potential for damage of the internal electrical elements by the large amount of artificial blood from the tracheostomy tube. However, a mechanical pump provided a useful means of active bleeding in this low-fidelity manikin. Research MethodsWe provided a pre- and post-simulation questionnaire for the 33 emergency medicine residents who participated in this simulation. There were 11 residents from each of the PGY-1, PGY-2 and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-survey and 33 residents (100%) completed the post-survey. For our questions, we used a 5-point Likert Scale to assess a resident's knowledge of the learning objectives within this simulation. ResultsResponses from our pre- and post- survey indicated a significant improvement in knowledge about a tracheoinnominate artery fistula as well as the general management of tracheostomy complications in the emergency department. DiscussionThis simulation is a useful educational tool for instructing emergency medicine residents on optimal management of tracheostomy emergencies such as a TIAF. The interprofessional teaching by an emergency medicine attending and mid-level (PGY-3) otolaryngology resident allowed for a richer and more detailed discussion during the debriefing. Throughout the case, the emergency medicine attending played the role of a bedside nurse and offered supportive, clinical cues when bleeding recurred. The otolaryngology resident played the role of a family member and offered helpful cues during the history and exam portion of the case. Following the case, both content experts provided useful clinical insight during the debriefing. If staffing availability permits, it might be advantageous to use additional simulation-trained personnel to play the roles of the nurse and family member, thus allowing the emergency medicine attending and otolaryngology content experts to simply view the case from the control room and perform the debriefing. TopicsTracheostomy, surgical airway, tracheoinnominate artery fistula, bleeding from tracheostomy site, complications with tracheostomies, hemorrhagic shock.
"Not only did I learn more substantive law than in any other course I've taken, but I learned why I needed to learn all those things." Alumnus of a legal simulation courseSimulations create and use a ...complete environment within which students can interact to apply theory and practice skills to real-world issues related to their discipline. Simulations constitute a powerful tool for learning. They allow teachers simultaneously to integrate multiple teaching objectives in a single process. They motivate students, provide opportunities for active participation to promote deep learning, develop interactive and communication skills, and link knowledge and theory to application.This book provides an introduction to the use of simulations - from creating simple scenarios that can be completed in a single class period, to extended, complex simulations that may encompass a semester's curriculum. Assuming no prior experience in their use, the authors provide a recipe approach to selecting and designing scenarios for all sizes of class; offer guidance on creating simulated environments to meet learning objectives; and practical advice on managing the process in the classroom through to the crucial processes of debriefing and assessment. The detailed concluding description of how to plan and manage a complex simulation -- complete with its sample scenario and examples of documentation - provides a rich demonstration of the process. This book will appeal to anyone, in virtually any field of study, looking for effective ways to bridge the gap between academic learning and discipline-specific practice.
Simulation from the truncated multivariate normal distribution in high dimensions is a recurrent problem in statistical computing and is typically only feasible by using approximate Markov chain ...Monte Carlo sampling. We propose a minimax tilting method for exact independently and identically distributed data simulation from the truncated multivariate normal distribution. The new methodology provides both a method for simulation and an efficient estimator to hitherto intractable Gaussian integrals. We prove that the estimator has a rare vanishing relative error asymptotic property. Numerical experiments suggest that the scheme proposed is accurate in a wide range of set-ups for which competing estimation schemes fail. We give an application to exact independently and identically distributed data simulation from the Bayesian posterior of the probit regression model.
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BFBNIB, FZAB, GIS, IJS, INZLJ, IZUM, KILJ, NLZOH, NMLJ, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK, ZRSKP
This scenario was developed to educate junior and senior emergency medicine (EM) residents. It can also be cut short to be used for 4th year EM bound medical students.
Meningococcal meningitis is a ...devastating disease that can cause severe neurologic sequelae if not diagnosed early and treated appropriately. In 2017, Centers for Disease Control reports a rate of 350 cases (0.11 cases per 100,000) which makes it an extremely rare disease. The highest reported rate is under the age of 1 (0.69 in 100,000) with second peak in adolescents and young adults between the ages of 16 and 23 (0.29 in 100,000) and third peak in patients above the age of 80 (0.49 in 100,000).1 The presentation for bacterial meningitis includes neck stiffness, fever, vomiting, photophobia, positive Kernig and Brudzinski's sign, and lethargy. In addition, 80% patients with meningococcal meningitis have rash during some stage of their disease.2 A feared and rare complication of severe meningococcal disease is Waterhouse-Friderichsen Syndrome (WFS) which carries a high mortality rate of 20%. Therefore, early diagnosis and rapid management of meningococcal disease is highly imperative.3 This simulation case was written to demonstrate the presentation of meningococcal meningitis and to discuss the management of WFS.
By the end of this simulation session, learners will be able to: (1) manage a patient with altered mental status (AMS) with fever while maintaining a broad differential diagnosis, (2) recognize the risk factors for meningococcal meningitis, (3) manage a patient with worsening shock and perform appropriate resuscitation, (4) develop a differential diagnosis for thrombocytopenia and elevated international normalized ratio (INR) in an altered febrile hypotensive patient with rash, (5) manage the bleeding complications from WFS, (6) discuss the complications of meningococcal meningitis including WFS, and (7) review when meningitis prophylaxis is given.
This session was conducted using high-fidelity simulation. It was immediately followed by an in-depth debriefing session. The session was conducted on a total of 9 EM residents from various levels of training who actively participated during the case and 25 residents who were observers. There was 1 simulation instructor running the session and 1 simulation technician who acted as a nurse.
After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the learners. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right amount of complexity, (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. A ten-item Likert scale was used to collect the responses.
Ten learners responded to the survey. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning and improving patient care. They also agreed that it helped in improving medical knowledge. The post-session debrief was found to be very helpful by all the learners..
This high-fidelity simulation case was not only cost-effective but also was very helpful in teaching EM residents how to manage a patient with meningococcal meningitis and WFS. The case was started with the patient presenting with altered mental status and fever, and as the case unfolded, mental status and shock worsened allowing the learners to intubate and resuscitate. Overall, learners also found the discussion of prophylaxis valuable.
Meningitis, altered mental status, medical simulation, infectious disease, neurology, septic shock, Waterhouse-Friderichsen Syndrome, hematology.
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