AudienceThis scenario was developed to educate emergency medicine (EM) interns but can be used to educate medical students and junior residents. IntroductionTorsade de Pointes (TdP) is a rare but ...potentially fatal arrythmia if not quickly diagnosed and properly treated. TdP is defined as a polymorphic ventricular tachycardia (VT) characterized by an oscillatory change in amplitude around an isoelectric line that is associated with a QTc prolongation on the electrocardiogram (ECG).1 It has been well described to predispose to ventricular fibrillation and arrhythmic death. QTc prolongation can be congenital or acquired. Between 1 in 2000 to 20,000 have the genetic mutation for QTc prolongation.1 Acquired QTc is most commonly drug related leading to electrolyte abnormalities. 2 Around 28% of cases of TdP are associated with hypokalemia and hypomagnesemia.2 Several European centers estimate 0.8 to 1.2 per million people per year are drug induced.1 Patients with TdP most commonly presents with syncope, palpitations, and dizziness.2 While 50% are asymptomatic, up to 10% of patients will present in cardiac arrest.1 It is imperative for EM physicians to be able to recognize TdP as it can quickly decompensate into a ventricular fibrillation and sudden death. These patients require management of electrolyte abnormalities, ventricular dysrhythmias, and cardiac death.2 This simulation case will demonstrate treatment strategies for TdP with electrolyte repletion, antiarrhythmics, and defibrillation. Educational ObjectivesBy the end of this simulation session, learners will be able to: 1) formulate appropriate work-up for altered mental status (AMS) 2) recognize hypokalemia and associated findings on ECG 3) address hypomagnesemia in a setting to hypokalemia 4) manage pulseless VT by following advanced cardiac life support (ACLS) 5) recognize and address TdP 6) provide care after return of spontaneous circulation (ROSC) 7) consult intensivist and admit to intensive care unit (ICU). Educational MethodsThis session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. Each session had three EM first-year residents and six observers. There was one simulation instructor running the session and one simulation technician who acted as a nurse. Research MethodsAfter 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) was the case believable? (2) did the case have the right amount of complexity? (3) did the case help improve medical knowledge and patient care? (4) did the simulation environment gave a real-life experience? (5) did the debriefing session after simulation help improve knowledge? A Likert scale was used to collect the responses. ResultsThis case was performed once a year for 2 years in a row. There was a total of 19 respondents from both years. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning and in improving medical knowledge and patient care. All of them found the post-session debrief to be very helpful. Two of them felt neutral about the case being realistic. DiscussionThis high-fidelity simulation was a realistic way of educating learners on how to manage hypokalemia and hypomagnesemia leading to TdP. Cost-effectiveness varies depending on what is available at individual simulation laboratories. Learners are forced to start with a broad differential for the patient who presents with AMS. As they manage the case, the patient quickly decompensates into a fatal arrhythmia due to electrolyte abnormalities. Learners enforced their knowledge on leading ACLS, intubation skills, and treating TdP with electrical conversion and electrolyte repletion. TopicsHypokalemia, hypomagnesemia, torsades de pointes, altered mental status, medical simulation.
Aortic Dissection Presenting as a STEMI Yee, Jennifer; Kendle, Andrew P
Journal of education & teaching in emergency medicine,
07/2022, Letnik:
7, Številka:
3
Journal Article
Recenzirano
Odprti dostop
AudienceThis scenario was developed to educate emergency medicine residents on the presentation and management of a patient with a Stanford type A aortic dissection. IntroductionChest pain is one of ...the most common chief complaints seen in the emergency department with a deadly differential diagnosis list. A "can't miss" diagnosis, aortic dissection occurs when an intimal tear creates a false lumen in the aorta, with a variably reported incidence of approximately 2.5-5 per 100,000 person-years.1 This amounts to an estimated 8,000-16,000 cases per year in the United States with a mortality likely underestimated due to prehospital death ranging from 20-40% within 24 hours and 30-50% at 5 years.2,3,4 There is a reported increase in mortality by 1% for every hour the diagnosis is delayed, and half of diagnoses are made greater than 24 hours after presentation.5 The symptoms can range from chest pain to back pain, abdominal pain or extremity pain, to syncope or isolated neurologic deficits, even to shock or cardiac arrest.6 Aortic dissection is most commonly categorized into two groups: Stanford type A, involving the ascending aorta, and Stanford type B, involving only the descending aorta, and are generally managed surgically vs. medically respectively based on this paradigm.7,8 Stanford type A can be complicated by severe aortic regurgitation, pericardial tamponade or coronary artery occlusion mimicking ST-segment elevation myocardial infarction (STEMI). These potentials make it important to switch from heuristic to analytical thinking when developing a differential diagnosis.9 A high index of suspicion with early recognition and management is critical in this catastrophic disease state, especially given the propensity for complications and a wide variety of presentations. Educational ObjectivesAt the conclusion of the simulation session or during the debriefing session, learners will be able to: 1) Verbalize the anatomical differences and management of Stanford type A and type B aortic dissections, 2) Describe physical exam findings that may be found with ascending aortic dissections, 3) Describe the various clinical manifestations of the propagation of aortic dissections, 4) Discuss the management of aortic dissection, including treatment and disposition. Educational MethodsThis session was conducted using a simulation scenario with a high-fidelity manikin as the patient and confederate/actor in the nursing role, followed by a post-scenario debriefing session on the presentation, differential diagnosis, potential physical exam findings, and management of patients with aortic dissection. Debriefing methods may be left to the discretion of the educators, but the authors have utilized advocacy-inquiry techniques.10 This scenario may also be run as an oral board examination case. Research MethodsThe residents are provided an electronic survey at the completion of the debriefing session to anonymously rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center. ResultsTwenty learners completed a feedback form. This session received all 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than one isolated 5 score. The lowest average score was 6.5 for, "Before the simulation, the instructor set the stage for an engaging learning experience," and the highest average score was 6.84 for, "The instructor identified what I did well or poorly - and why." Feedback from the residents was overwhelmingly positive (available upon request). All groups initially gave aspirin upon identification of the STEMI and several gave heparin. Debriefing topics included STEMI mimics, physical exam findings for aortic dissection, imaging and laboratory workup for aortic dissection, blood pressure and heart rate goals and pharmacologic management, uncomplicated STEMI management, and Type I versus Type II decision-making. DiscussionThis is an easily reproducible method for reviewing management of patients with aortic dissection. There are multiple potential presentations and complications of aortic dissections to further customize the experience for learners' needs. While it was discussed during debriefing that heparin administration was unlikely to cause immediate cardiopulmonary arrest, this state was included to reflect downstream hemorrhagic complications that may occur in the setting of antiplatelet administration for acute aortic dissection. Facilitators may choose to omit the arrest at their discretion. TopicsMedical simulation, emergency medicine, aortic dissection, ST-elevation myocardial infarction, cardiovascular emergencies, hypertensive emergencies, STEMI mimics, vascular surgery, cardiothoracic surgery.
Cyanide Poisoning Doman, Ghadeer; Aoun, Jihad; Truscinski, Joshua ...
Journal of education & teaching in emergency medicine
7, Številka:
3
Journal Article
Recenzirano
Odprti dostop
The goal of this simulation is to educate emergency medicine students, residents, attending physicians, and mid-level practitioners to recognize, diagnose, and manage acute cyanide toxicity.
Cyanide ...has an almond scent and is a naturally occurring compound. It is present within many different types of plants and fruits including apricots, apples, peaches, lima beans, and cassava plants but is harmless.1 The trace amounts of cyanide found within organic materials is of little concern because its high reactivity causes it to be metabolized rapidly and create other compounds. However, modern synthetic materials such as plastics, papers, textiles, and machinery can release a much greater concentration of hydrogen cyanide when exposed to high temperatures.1 As the use of contemporary nitrogen-containing synthetic polymers has expanded, the possibility of cyanide toxicity has become increasingly common and severe. Hydrogen cyanide is especially dangerous to humans because the gaseous form reacts quickly upon inhalation.2When cyanide enters the body via inhalation, it blocks the cells from utilizing oxygen by binding to the cytochrome oxidase in the mitochondria.2 The inability of the cell to use oxygen forces cells from aerobic metabolism into anaerobic metabolism. Anaerobic metabolism results in the production of lactic acid, which causes metabolic acidosis.3 The human body cannot sustain itself with the lack of oxygen and anaerobic metabolism for a prolonged period of time. Ultimately, the body will suffer cardiorespiratory arrest.1Symptoms of cyanide toxicity include headache, nausea, shortness of breath, and altered mental status.1 These are similar to those of carbon monoxide and carbon dioxide inhalation. However, symptoms of cyanide toxicity cannot be treated with supplemental oxygen as carbon monoxide and carbon dioxide are. Cyanide toxicity must be treated with an antidote - sodium thiosulfate, sodium nitrite, and hydroxocobalamin.4 Each of the antidotes works by binding with the highly reactive cyanide, neutralizing the compound, and converting it into a water-soluble product that will be cleared through renal excretion.4Fire victims often present to the emergency department critically ill. They will likely have obvious external thermal burns and traumatic injuries; however, it is important for emergency personnel to recognize the respiratory distress and metabolic derangements that are most likely occurring due to toxic gas inhalation. People who are trapped within a burning structure are exposed to carbon monoxide, carbon dioxide, and cyanide from the combustion of contents within the building. These toxic gasses will cause severe tissue hypoxia without significant vital sign changes.5 The respiratory distress and metabolic compromise will be acutely more fatal than the obvious external injuries and burns. The challenge in treating these patients is for the healthcare team to know the differential diagnoses, prioritize airway, breathing and circulation, and to empirically treat the patient as if they have a confirmed exposure.It is estimated that 35% of all fire victims have toxic levels of cyanide upon arrival to the emergency room.2 Acute cyanide toxicity can become fatal within minutes; however, a prompt diagnosis and treatment can be lifesaving. Unfortunately, due to the limited amount of time the human body can sustain anaerobic metabolism and tissue hypoxia, blood test results are not available in time to be clinically applicable.2 Rather, the emergency room personnel must begin treatment immediately upon recognizing that toxic smoke inhalation may have occurred.We understand the importance of knowing how to treat fire victims. Therefore, the goal of this simulation case is to expose the emergency providers to cyanide poisoning and educate emergency providers about the critical steps of how to approach, diagnose, and treat cyanide toxicity.
After the completion of this simulation, participants will have learned how to: 1) identify clues of smoke inhalation based on a physical examination; 2) identify smoke inhalation-induced airway compromise and perform definitive management; 3) create a differential diagnosis for victims of fire cyanide poisoning, carbon monoxide, and carbon dioxide; 4) appropriately treat cyanide poisoning; 5) demonstrate the importance of preemptively treating for cyanide poisoning; 6) perform an initial physical examination and identify physical marks suggesting the patient is a fire and smoke inhalation victim; and 7) familiarize themselves with the Cyanokit and treatment with hydroxocobalamin.
This is a high-fidelity simulation case in which participants work through a case of a patient who has been exposed to fire. The participants will be able to work hands-on to evaluate, diagnose, and treat cyanide poisoning in an emergency event. Afterwards, there will be a small group discussion and debriefing of the case in order to review patient care skills, interpersonal and communication skills, medical knowledge, and system-based practice.
The participants were instructed to complete a survey before and after the simulation case. A quality Likert Scale was used to assess the participants' comfort level of diagnosing, treating, and managing a patient with toxic smoke inhalation. A score of 1 represented a negative experience and 5 represented a very positive experience. The surveys were then reviewed by the research team to determine if the simulation case improved the participants' comfort level. The survey answers were compared collectively, as well as individually, and were analyzed between the pre-simulation and post-simulation results.
Our simulation involved 25 participants: 20 participants were emergency medicine resident physicians and 5 were 4th-year medical students. In the pre-simulation survey, participants reported a mean of 2.7 out of 5 when asked to rate their confidence in their ability to treat a smoke inhalation victim. The post-simulation survey showed a significant increase to a mean of 3.5 out of 5. Participants were also asked to evaluate the usefulness of the simulation: 15 participants rated the case as a 5, which represented "very useful," and the other 10 participants rated the case as a 4, which represented "useful." The mean value when asked to assess the simulation case's usefulness and applicability in emergency medicine was 4.6 out of 5.
This simulation allows providers to focus on victims of fire. Fire victims are often critically ill and require time sensitive treatment. This simulation gives providers a chance to review their knowledge and prepare them for real life cases. Based on the survey results, the simulation improved awareness and understanding of the symptoms of acute cyanide toxicity and improved the participant's ability to recognize, diagnose, and treat cyanide poisoning.
Cyanide toxicity, carbon monoxide toxicity, cyanide antidote, fire victim, intubation, airway intervention, oxygen treatment, history taking, lab testing ordering, symptom identification, interpretation of lab results, emergency medicine simulation.
" Power system modelling and scripting is a quite general and ambitious title. Of course, to embrace all existing aspects of power system modelling would lead to an encyclopedia and would be likely ...an impossible task. Thus, the book focuses on a subset of power system models based on the following assumptions: (i) devices are modelled as a set of nonlinear differential algebraic equations, (ii) all alternate-current devices are operating in three-phase balanced fundamental frequency, and (iii) the time frame of the dynamics of interest ranges from tenths to tens of seconds. These assumptions basically restrict the analysis to transient stability phenomena and generator controls. The modelling step is not self-sufficient. Mathematical models have to be translated into computerprogramming code in order to be analyzed, understood and ""experienced"". It is an object of the book to provide a general framework for a power system analysis software tool and hints for filling up this framework with versatile programming code.This book is for all students and researchers that are looking for a quick reference on power system models or need some guidelines for starting the challenging adventure of writing their own code."
Computer simulation of molecular systems enables structure–energy–function relationships of molecular processes to be described at the sub‐atomic, atomic, supra‐atomic, or supra‐molecular level. To ...interpret results of such simulations appropriately, the quality of the calculated properties must be evaluated. This depends on the way the simulations are performed and on the way they are validated by comparison to values Qexp of experimentally observable quantities Q. One must consider 1) the accuracy of Qexp, 2) the accuracy of the function Q(rN) used to calculate a Q‐value based on a molecular configuration rN of N particles, 3) the sensitivity of the function Q(rN) to the configuration rN, 4) the relative time scales of the simulation and experiment, 5) the degree to which the calculated and experimental properties are equivalent, and 6) the degree to which the system simulated matches the experimental conditions. Experimental data is limited in scope and generally corresponds to averages over both time and space. A critical analysis of the various factors influencing the apparent degree of (dis)agreement between simulations and experiment is presented and illustrated using examples from the literature. What can be done to enhance the validation of molecular simulation is also discussed.
Assumptions, approximations, and pitfalls: Validation of the results of molecular simulations is a process beset with theoretical and practical problems. The effects of the various assumptions and approximations involved in the formulation of a molecular model and its simulation and the pitfalls of comparing simulated with experimental data are discussed. Ways to enhance validation of molecular simulation are suggested.
Breaking Bad News in the Emergency Department Siraco, Susan; Bitter, Cindy; Chen, Tina
Journal of education & teaching in emergency medicine,
04/2022, Letnik:
7, Številka:
2
Journal Article
Recenzirano
Odprti dostop
AudienceThe primary audience for this simulation is emergency medicine (EM) residents, but this curriculum could also be used for EM-bound medical students. IntroductionBreaking bad news is a ...difficult but necessary skill for EM physicians. Bad news can range from informing family that a patient is in the emergency department (ED), to shared decision making regarding a life-threatening situation, to family notification of patient death.1 Although there are many structured approaches to death notification and breaking bad news, such as GRIEV_ING2 and SPIKES,3 EM physicians often lack confidence in their ability to effectively communicate bad news.1,4-6 Goals of care discussions and shared decision making become especially complex in the ED environment because critically ill patients often arrive without advanced directives, lack pre-existing rapport with the EM physician, and may require rapid engagement with surrogate decision-makers on emergent interventions.7 This simulation curriculum was developed to provide EM trainees with a psychologically safe environment to practice effective communication in breaking bad news, incorporating clinical scenarios commonly encountered in the ED. Educational ObjectivesAt the conclusion of these two simulation cases, learners will be able to 1) recognize signs of poor prognosis requiring emergent family notification, 2) take practical steps to contact family using available resources and personnel, 3) establish goals of care through effective family discussion, 4) use a structured approach, such as GRIEV_ING, to deliver bad news to patients' families, and 5) name the advantages of family-witnessed resuscitation. Educational MethodsThis curriculum consists of two simulation cases. Prior to the simulation, learners were assigned pre-reading on the GRIEV_ING approach to death notification, and how this approach could translate into breaking bad news in the ED. Although we chose to implement GRIEV_ING at our institution, other structured approaches (such as SPIKES) are reasonable as well. Each simulation case was conducted using a high-fidelity mannequin capable of intubation, respiratory examination findings such as abnormal breath sounds, and dynamic vital sign changes. Both cases required a standardized patient or other case confederate. Following each case, the learners underwent a debriefing session discussing how to break bad news in a high-pressure, time-sensitive ED environment. This case was designed as a high-fidelity simulation with a standardized patient, but it can be adapted to a low-fidelity simulation with a standardized patient. Research MethodsLearners filled out a survey before and after the simulation describing their confidence in establishing goals of care with patients and surrogates, notifying family members of bad news in the ED, and their use of a consistent approach to breaking bad news. Scores were analyzed using the related-samples Wilcoxon signed rank test. ResultsLearners exhibited improvement on all surveyed items, with statistically significant improvement on the survey item asking about their confidence in implementing a consistent approach to breaking bad news. Qualitative feedback was positive, with learners consistently endorsing the value of practicing difficult conversations in a simulated environment. First- and second-year residents appeared to benefit from the cases more strongly than senior residents. DiscussionThese cases provided a safe environment for learners to practice a structured approach to breaking bad news. Learners tended to aggressively resuscitate the elderly septic patient and perform invasive procedures, such as intubation and mechanical ventilation, prior to contacting family or establishing goals of care, which generated good discussion points during debriefing. TopicsSimulation, breaking bad news, goals of care discussion, death notification, sepsis, cardiac arrest, family witnessed resuscitation.
AudienceEmergency medicine and pediatric residents, and pediatric emergency medicine (PEM) fellows. IntroductionBotulism is a rare but serious cause of infant hypotonia, vomiting, and respiratory ...failure. The differential diagnosis and management of a hypotonic infant with progressive weakness leading to respiratory failure is a rare presentation with high morbidity and mortality.1 Infants with botulism generally present with vague complaints that progressively worsen over time.2 Recognition of descending paralysis in an infant as well as signs of respiratory failure are key to preventing an adverse outcome. A key component of botulism treatment is recognizing the need to mobilize local resources to obtain BabyBIG® (botulism immune globulin). This process can and should begin in the emergency department. Educational ObjectivesAfter this simulation learners should be able to: 1) develop a differential diagnosis for the hypotonic infant, 2) recognize signs and symptoms of infant botulism, 3) recognize respiratory failure and secure the airway with appropriate rapid sequence intubation (RSI) medications, 4) initiate definitive treatment of infant botulism by mobilizing resources to obtain antitoxin, 5) continue supportive management and admit the patient to the pediatric intensive care unit (PICU), 6) understand the pathophysiology and epidemiology of infant botulism, 7) develop communication and leadership skills when evaluating and managing critically ill infants. Educational MethodsThis simulation case was performed using a high-fidelity Laerdal SimBaby with intubating capabilities and real-time vital sign monitoring. Additionally, this case can be performed with low fidelity manikins with supplemental scripting and visual stimuli. With minor adjustments, this case could be modified into an oral boards case. Research MethodsWe obtained feedback from a convenience sample of random participants after the simulation case and debrief were completed. The sample of emergency medicine residents (N=21) and PEM fellow (N=1) completed 5 questions on a 5-point Likert scale. ResultsThe emergency medicine residents and PEM fellow had mostly favorable feedback regarding the simulation and debriefing. Most strongly agreed or agreed that this would improve their performance in an actual clinical setting. DiscussionInfant botulism is a rare condition, presenting as vague non-specific complaints that worsen over time. It is important to differentiate infant botulism from other causes of weakness, hypotonia, and respiratory failure. This case presents learners with a high acuity, rare case of infant botulism and allows them to work through a complex pediatric patient encounter in a psychologically safe space. The presence of a standardized patient to play the patient's parent is key to assess learners' nontechnical communication skills and to increase fidelity during the simulation. TopicsInfant botulism, pediatric emergency medicine, respiratory failure, hypotonia, toxicology.
Ecological Models and Data in R is the first truly practical introduction to modern statistical methods for ecology. In step-by-step detail, the book teaches ecology graduate students and researchers ...everything they need to know in order to use maximum likelihood, information-theoretic, and Bayesian techniques to analyze their own data using the programming language R. Drawing on extensive experience teaching these techniques to graduate students in ecology, Benjamin Bolker shows how to choose among and construct statistical models for data, estimate their parameters and confidence limits, and interpret the results. The book also covers statistical frameworks, the philosophy of statistical modeling, and critical mathematical functions and probability distributions. It requires no programming background--only basic calculus and statistics. Practical, beginner-friendly introduction to modern statistical techniques for ecology using the programming language R Step-by-step instructions for fitting models to messy, real-world data Balanced view of different statistical approaches Wide coverage of techniques--from simple (distribution fitting) to complex (state-space modeling) Techniques for data manipulation and graphical display Companion Web site with data and R code for all examples
This book offers tools, modeling principles and state-of-the art simulation models for discrete-event based network simulations. Wired and wireless networks and tools are each addressed in separate ...sections, and a variety of simulation engines are included.
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