AudienceThe target audience of this simulation is emergency medicine residents and medical students. The simulation is based on a real case of a 12-year-old male who presented obtunded with shortness ...of breath and hypothermia who was ultimately diagnosed with diabetic ketoacidosis (DKA) and pneumomediastinum. This case highlights the diagnosis and management of an adolescent with new onset diabetic ketoacidosis and pneumomediastinum with deterioration of status, as well as important ventilator settings if intubation is required in the setting of diabetic ketoacidosis.BackgroundType 1 diabetes is a common disease in the pediatric population with the prevalence being approximately 2.15 per 1000 youths and diabetic ketoacidosis being the presenting status in 30-40% of the patients.1 Physicians who evaluate a child with altered mental status must have diabetic ketoacidosis in their differential. In the setting of mechanical ventilation in patients with diabetic ketoacidosis (DKA), special care must be taken. Mechanical ventilation in these patients comes with increased risk, morbidity, and mortality. Risk factors for pneumomediastinum include lung disease such as asthma, chronic obstructive pulmonary disease (COPD), and malignancy, but also can occur in the acute setting of vomiting or trauma.2.Educational ObjectivesBy the end of the simulation, learners will be able to: 1) develop a differential diagnosis for an adolescent who presents obtunded with shortness of breath; 2) discuss the management of diabetic ketoacidosis; 3) discuss management of hypothermia in a pediatric patient; 4) discuss appropriate ventilator settings in a patient with diabetic ketoacidosis; and 5) demonstrate interpersonal communication with family, nursing, and consultants during high stress situations.Educational MethodsThis is a high-fidelity simulation that allows learners to manage the diagnosis and treatment of diabetic ketoacidosis and hypothermia in an adolescent patient. Participants participated in a debriefing after the simulation. There should be approximately 4-5 learners per case. This simulation was performed in 3 sessions. Each learner performed this simulation one time.Research MethodsThe 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 open-ended written questions. This case was trialed with residents in their first through third years of training as well as fourth year medical students.ResultsFeedback was very positive, with 19 residents completing the post-simulation survey. They enjoyed the case and reported they would feel more comfortable in a comparable situation in the future. Four survey questions were asked of the participants. On average, learners stated they felt the simulation improved their ability to manage a pediatric DKA patient, and their knowledge of complications and appropriate ventilator settings improved (modes of 5, 4 and 5, respectively).DiscussionDiabetic ketoacidosis is a common and critical diagnosis for emergency medicine physicians to consider in the setting of altered mental status in a pediatric patient. This simulation has multiple steps and is based on a real case of an obtunded and hypothermic pediatric patient who was ultimately diagnosed with diabetic ketoacidosis complicated by pneumomediastinum.TopicsDiabetic ketoacidosis, pneumomediastinum, hypothermia, altered mental status, pediatrics, adolescent, intubation, hypoxia, ventilator settings, cardiac arrest, emergency medicine, medical simulation.
Inhalational Injury Secondary to House Fire O'Neill, Ryan; Ostro, Benjamin M; Yee, Jennifer
Journal of education & teaching in emergency medicine,
10/2023, Letnik:
8, Številka:
4
Journal Article
Recenzirano
Odprti dostop
AudienceThis scenario was developed to educate emergency medicine residents on the diagnosis and management of patients with an inhalational airway injury secondary to a house fire.BackgroundBurn ...injuries are a common occurrence encountered by the emergency physician. According to the National Hospital Ambulatory Medical Care Survey, around 371,000 patients were treated in emergency departments for fire or burn injuries across the United States in 2020. This represents around 1% of emergency department visits related to injury, poisoning, or adverse effects.1 One of the most dangerous and time critical aspects of managing severely burned patients is inhalation injury. Inhalation injury is a relatively vague term which may refer to pulmonary exposure to a wide range of chemicals in various forms. In the context of burn patients, this is most often smoke exposure. It is critical that the emergency medicine provider rapidly identifies the potential for an inhalational injury in order to determine the need for definitive airway management. It is also important that the provider has the necessary skills and systematic approach to manage what is likely to be a difficult airway. Furthermore, providers must then have the knowledge of how to best manage and resuscitate these severely burned patients post-intubation.Educational ObjectivesAt the conclusion of the simulation session, learners will be able to: 1) recognize the indications for intubation in a thermal burn/inhalation injury patient; 2) develop a systematic approach to an inhalational injury airway; and 3) recognize indications for transfer to burn center.Educational MethodsThis session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of inhalational airway injury secondary to a house fire. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case.Research MethodsOur residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form2 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7.ResultsNine learners completed a feedback form. This session received all 6 & 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than one isolated 5 score.DiscussionThis is a cost-effective method for reviewing inhalational airway injury diagnosis and management. The case may be modified for targeted audiences, expected resources, and learning objectives, such as removal of a bronchoscope availability in settings which are expected to be resource-limited. Some readers may choose to focus on other aspects of burn management instead of airway securement such as cyanide and/or carbon monoxide toxicity. We encourage readers to limit the number of learning objectives because airway algorithms and troubleshooting for this scenario was a rich, stand-alone debriefing. There was not enough time to review in detail all nuanced aspects of the burned patient, including: Lund-Browder versus rule of 9's, modified Brooke versus Parkland formulas, indications for and completion of escharotomies, and/or identification and treatment of cyanide and carbon monoxide toxicity.TopicsMedical simulation, burns, airway emergencies, emergency medicine.
Ventricular Tachycardia Menon, Rohit; Emerson, Geremiha; Yee, Jennifer
Journal of education & teaching in emergency medicine
8, Številka:
4
Journal Article
Recenzirano
Odprti dostop
This scenario was developed to educate emergency medicine residents on the diagnosis and management of ventricular tachycardia (VT) that is refractory to single dose anti-arrhythmic management.
...Electrical storm, defined as three or more episodes of sustained VT, ventricular fibrillation, or appropriate shocks from an implantable cardioverter defibrillator within 24 hours,1 has a mortality rate up to 14% in the first 48 hours.2 Ventricular tachycardia may present in a heterogenous fashion, not only with stable versus unstable clinical presentations, but also with different electrocardiographic morphologies and etiologies.1 Understanding how to rapidly diagnose, treat, and utilize second or third-line treatments is vital in the setting of refractory ventricular tachycardia rather than relying on the success of first-line agents. Appreciation for what medications are readily available in your crash cart and medication dispensing cabinet is critical for timely management for refractory ventricular tachycardia.
At the conclusion of the simulation session, learners will be able to: 1) identify the different etiologies of VT, including structural heart disease, acute ischemia, and acquired or congenital QT syndrome; 2) describe confounding factors of VT, such as electrolyte abnormalities and sympathetic surge; 3) describe how to troubleshoot an unsuccessful synchronized cardioversion, including checking equipment connections, increasing delivered energy, and changing pad placement; 4) compare and contrast treatments of VT based on suspected underlying etiology; 5) describe reasons to activate the cardiac catheterization lab other than occlusive myocardial infarction; and 6) identify appropriate disposition of the patient to the cardiac catheterization lab.
This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of VT. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case.
Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario.
The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form
with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Twelve learners completed a feedback form. This session received 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than three isolated 5 scores. The lowest average score was 6.67 for "Before the simulation, the instructor set the stage for an engaging learning experience." The highest average score was 7 for "The instructor helped me see how to improve or how to sustain good performance." The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: "Excellent care and debrief." Specific scores are available upon request.
This is a cost-effective method for reviewing VT diagnosis and management. The case may be modified for appropriate audiences, such as describing what medications may be readily available in a free-standing emergency department or pre-hospital setting.
Medical simulation, ventricular tachycardia, cardiac emergencies, dysrhythmias, cardiology, emergency medicine.
Simulation studies are computer experiments that involve creating data by pseudo‐random sampling. A key strength of simulation studies is the ability to understand the behavior of statistical methods ...because some “truth” (usually some parameter/s of interest) is known from the process of generating the data. This allows us to consider properties of methods, such as bias. While widely used, simulation studies are often poorly designed, analyzed, and reported. This tutorial outlines the rationale for using simulation studies and offers guidance for design, execution, analysis, reporting, and presentation. In particular, this tutorial provides a structured approach for planning and reporting simulation studies, which involves defining aims, data‐generating mechanisms, estimands, methods, and performance measures (“ADEMP”); coherent terminology for simulation studies; guidance on coding simulation studies; a critical discussion of key performance measures and their estimation; guidance on structuring tabular and graphical presentation of results; and new graphical presentations. With a view to describing recent practice, we review 100 articles taken from Volume 34 of Statistics in Medicine, which included at least one simulation study and identify areas for improvement.
Simulation is the imitation of the operation of a real-world process or system over time. The act of simulating something first requires that a model be developed; this model represents the key ...characteristics or behaviors of the selected physical or abstract system or process. The model represents the system itself, whereas the simulation represents the operation of the system over time.
Alcohol Withdrawal with Delirium Tremens Schwebach, Courtney; Vempati, Amrita
Journal of education & teaching in emergency medicine
8, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Emergency medicine (EM) residents (1
year and 2
year levels), 4th year medical students and advanced practice providers.
Alcohol use has played a major role in causing significant morbidity and ...mortality for patients. In 2016, it was the 7th leading risk factor for deaths and disability-adjusted life years globally.1 Among heavy alcohol users admitted for hospital management, the incidence of alcohol withdrawal syndrome is estimated to be 1.9 to 6.7%.1 Alcohol withdrawal (AW) in the ED has been associated with increased use of critical care resources, and frequent ED visits for alcohol-related presentations have been associated with mortality rates that are about 1-4% when withdrawal progresses to delirium tremens (DTs).1 Patients with alcohol withdrawal can present in many different ways to the ED including anxiety, tachycardia, delirium tremens (DTs), seizures and severe autonomic dysfunction leading to severe sickness and death.2 Therefore, it is extremely important for an EM physician to recognize the signs of AW in patients and to manage the critically ill patients. In addition, Clinical Institute Withdrawal Assessment (CIWA) of alcohol was developed to assess severity of alcohol withdrawal in 1989.3 EM physicians should utilize CIWA to help determine the severity of AW.
By the end of the session, learner will be able to 1) discuss the causes of altered mental status, 2) utilize CIWA scoring system to quantify AW severity, 3) formulate appropriate treatment plan for AW by treating with benzodiazepine and escalating treatment appropriately, 4) treat electrolyte abnormalities by giving appropriate medications for hypokalemia and hypomagnesemia, and 5) discuss clinical progression and timing to AW.
This session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. The session was run during first year EM resident intern orientation, and it was run during two consecutive years. There was a total of 32 EM residents who participated. There was a total of 16 residents who actively managed the patient while the other 16 were observers. Each session had four learners and was run twice in two separate rooms. There was one simulation instructor running the session and one 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 participants. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right the amount of complexity (based on their Gestalt), (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. The responses were collected using a Likert scale of 1 to 5 with 1 being "Strongly disagree" and 5 being "Strongly agree."
There was a total of 15 respondents from both years. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning, in improving medical knowledge and in patient care. All of them found the post-session debrief to be very helpful. Two of them felt neutral about the case being realistic. The median response for questions 1, 3 and 5 is 5. The median response for questions 2 and 4 was 4. The range of responses for questions 1, 2, 3 and 5 was 4-5 while the range for question 4 was 3-5.
This high-fidelity simulation was a cost-effective and realistic way of educating learners on how to manage AW with DTs. Learners are forced to start with a broad differential for the patient who presents with AMS. As they recognize the cause of mental status, the patient quickly decompensates into developing severe agitation and autonomic dysfunction requiring learners to manage the patient and establish an airway. Learners found the case to be beneficial in learning the management of AW.
Alcohol withdrawal, delirium tremens, agitation, altered mental status.
This simulation is intended for MS4 or PGY-1 learners.
Both headache and syncope are common chief complaints in the emergency department (ED); however, subarachnoid hemorrhage (SAH) is uncommon ...(accounting for 1-3% of all patients presenting to the ED with headache), with near 50% mortality.1-3 It is important to recognize the signs and symptoms that point to this specific diagnosis. Once subarachnoid hemorrhage is suspected, it is critical to understand the appropriate workup to diagnose SAH, depending on the timing of presentation. Once SAH is diagnosed, appropriately managing the patient's glucose, blood pressure, and pain is important.
By the end of this case, the participant will be able to: 1) construct a broad differential diagnosis for a patient presenting with syncope, 2) name the history and physical exam findings consistent with SAH, 3) identify SAH on computer tomography (CT) imaging, 4) identify the need for lumbar puncture (LP) to diagnose SAH when CT head is non-diagnostic > 6 hours after symptom onset, 5) correctly interpret cerebral fluid studies (CSF) to aid in the diagnosis of SAH, and 6) specify blood pressure goals in SAH and suggest appropriate medication management.
High-fidelity simulation was utilized since this modality forces learners to actively construct a differential for syncope, recognize the possibility of subarachnoid hemorrhage, recall the need for lumbar puncture, and talk through management considerations in real time as opposed to a more passive lecture format.
Twenty emergency medicine residents and medical student learners completed the simulation activity. Each learner was asked to complete an eight question post-simulation survey. The survey addressed the utility and appropriate training level of the simulation activity while also including an open-ended prompt for suggestions for improvement.
Five PGY3, four PGY2, four PGY1, and seven medical students completed the survey. Ninety-five percent felt that the case was more helpful in a simulation format than in a lecture format. All learners felt that the simulation was an appropriate level of difficulty. Of the comments received, a few learners noted they preferred more complexity.
Overall, the educational content was effective in teaching about the SAH diagnostic algorithm, CSF interpretation, and blood pressure management in SAH. Overall, learners very much enjoyed the activity and felt it was appropriate for their level of training. The most common constructive feedback was to include more specific neurologic findings on physical examination to help guide the student to the diagnosis of SAH.
Syncope, subarachnoid hemorrhage, cerebrospinal fluid interpretation, lumbar puncture, intracranial bleed, blood pressure goals and management.
A aglomeração dos produtos acabados na mesa de seleção antes do processo de embalagem ocasiona avaria em alguns sabões, motivo pelo qual se fez necessário encontrar uma opção que forneça tempo ...suficiente ao operador para realizar a inspeçãoo visual e decidir quais produtos irão sofrer retrabalho. A fim de estudar possíveis soluções para o problema de fila na mesa de seleção do sabão em barra desta fábrica, foi proposto um esquema de simulação que segue todos os passos necessários para construção deste modelo. Dentre esses passos, encontram-se a definição dos objetivos, das restrições do sistema e das especificações da simulação. Por fim, foi feita a análise dos dados de saída coletados no modelo e identificados nos relatórios gerados pelo software Arena e calculado o intervalo de confiança para as três medidas de desempenho descritas nos objetivos do modelo: tempo de espera na mesa de seleção, quantidade de sabões para seleção e quantidade de sabões danificados. Após verificação e validação do modelo, foram listadas três sugestões que hipoteticamente podem reduzir a fila e sanar o problema de defeitos ocorridos na mesa de seleção.
Acute Exacerbation of COPD Pappas, Dominic; Vempati, Amrita
Journal of education & teaching in emergency medicine,
04/2023, Letnik:
8, Številka:
2
Journal Article
Recenzirano
Odprti dostop
AudienceThis case is targeted to emergency medicine residents of all levels. IntroductionShortness of breath (SOB) is one of the top ten most common chief complaints seen in the Emergency Department, ...accounting for close to 10% of presenting complaints.1 An acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a frequent culprit, accounting for roughly 15.4 million visits and 730,000 hospitalizations per year.2 The diagnosis of treatment of mild to moderate AECOPD can be relatively uncomplicated; however, multiple factors can increase the complexity of management and pose additional challenges that the emergency physician (EP) must be prepared for. Severe AECOPD can necessitate the need for both Non-invasive positive pressure ventilator (NIPPV) such as bi-level positive airway pressure (BiPAP) as well as emergent intubation. Furthermore, managing the ventilator settings in patients with an AECOPD is far from routine, requiring an intricate understanding of pulmonary physiology.3. Educational ObjectivesBy the end of this simulation, learners will be able to (1) assess for causes of severe shortness of breath, (2) manage severe COPD exacerbation by administering appropriate medications, (3) identify worsening clinical status and initiate NIPPV, (4) assess the causes of hypoxia after establishing endotracheal intubation and, (5) identify indication for needle decompression and perform chest tube thoracostomy. Educational MethodsThis simulation was conducted with a high-fidelity mannequin with a separate low fidelity chest tube mannequin that allowed for hands-on practice placing a chest tube. A total of 16 PGY-1 residents participated in the simulated patient encounter. Research MethodsFollowing the simulation and debrief session, all residents were sent a Likert scale survey via surveymonkey.com to assess the educational quality of the simulation. The survey contained the following questions; 1) Overall, this simulation was realistic and could represent a patient presentation in the Emergency Department, 2) Overall, the case contained complexity that challenged me as a learner, 3) This case helped to expand my medical knowledge, 4) I feel more confident in diagnosing and treating AECOPD, 5) I feel more confident in recognizing the indications for NIPPV and intubation, 6) This simulation offered an opportunity to improve my procedural skills, 7) I feel more confident in setting up the ventilator, 8) I feel more confident in addressing ventilator alarms. ResultsFollowing the simulation and debrief session, all the participants (n=16), were provided a survey to assess the educational quality of the simulation. There were a total of 12 respondents and a hundred percent of them agreed or strongly agreed that the case contained complexity that challenged them. All of the respondents agreed that the simulation case was realistic and that the case helped expand their medical knowledge. Furthermore, all the learners agreed or strongly agreed that the case helped them in improving their procedural skills. DiscussionThis case combines a mixture of high fidelity and medium fidelity components to encompass both clinical knowledge and procedural skills. This case is effective in expanding beyond the basic approach to managing an AECOPD patient and forces learners to address clinical deterioration, escalate airway interventions, manage ventilator settings, and address ventilator alarms, including placement of a chest tube. Residents commented that this case was very realistic and particularly challenging because it highlighted gaps in their clinical knowledge and procedural skills. Residents were most challenged by identifying when to escalate care as well as how to manage ventilator settings in AECOPD patients. TopicsAcute exacerbation COPD, intubation, positive pressure ventilation, ventilator alarms, chest tube thoracostomy.
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