Acute Exacerbation of COPD Pappas, Dominic; Vempati, Amrita
Journal of education & teaching in emergency medicine,
04/2023, Letnik:
8, Številka:
2
Journal Article
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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.
AudienceThis simulation is appropriate for senior and junior emergency medicine residents. IntroductionShortness of breath is a very common presentation in the emergency department and can range from ...mild to severe as well as a chronic or acute onset. In sympathetic crashing acute pulmonary edema (SCAPE), patients typically present with acute onset of dyspnea occurring within minutes to hours and have significantly elevated blood pressure.1 The condition of SCAPE falls into the spectrum of acute heart failure syndromes such as fluid overload pulmonary edema and congestive heart failure exacerbation.1. Educational ObjectivesAt the completion of the simulation and debriefing, the learner will be able to: 1) recognize the physical exam findings and presentation of SCAPE, 2) utilize imaging and laboratory results to further aid in the diagnosis of SCAPE, 3) initiate treatments necessary for the stabilization of SCAPE, 4) demonstrate the ability to assist with the stabilization and disposition of a patient via tele-medicine as determined by the critical action checklist and assessment tool below, 5) interpret the electrocardiogram (EKG) as atrial fibrillation with rapid ventricular response (AFRVR), and 6) recognize that SCAPE is the underlying cause of AFRVR and continue to treat the former. Educational MethodsThis simulation was performed using a high-fidelity mannequin. In order to simulate the telemedicine aspect, the learner evaluated the patient using a video conferencing interface while the two confederates were present with the high-fidelity mannequin. A debriefing session was held immediately after the simulation. Research MethodsThe educational content was evaluated by debriefing and verbal feedback provided immediately after the case. Additionally, a survey was emailed to participants and observers of the case to provide qualitative feedback. ResultsPost-simulation feedback was overall positive with participants and observers. Participants and observers felt this was a safe and realistic simulation of SCAPE and provided them with the opportunity to practice rapid recognition and treatment of this condition. DiscussionSympathetic crashing acute pulmonary edema falls into the spectrum of acute heart failure disorders, and rapid recognition and stabilization is vital for the patient's survival. This simulation case provided learners of all levels the chance to assess and treat a life-threatening condition with limited information in a safe and effective learning environment. The telemedicine component was used while conducting weekly didactics via zoom during the COVID-19 pandemic. Simulation is a large component of our didactic curriculum and implementing the telemedicine component into this case was worth the effort. It is important to familiarize our residents with telemedicine since we expect that it will become a larger part of the practice of emergency medicine in the future, allowing board-certified emergency medicine physicians to assist in providing care in rural emergency departments and smaller hospitals that may be staffed with less experienced providers. TopicsMedical simulation, tele-medicine, pulmonary edema, respiratory distress, cardiac emergencies, resuscitation.
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.
Emergency medicine residents, internal medicine residents, family medicine residents, community physicians, pediatricians, toxicology fellows.
There are over 600 compounds which contain ...anticholinergic properties.1 Medications with anticholinergic properties include antihistamines, atropine, tricyclic antidepressants, antipsychotics, topical mydriatics, antispasmodics, sleep aids, and cold preparations. 1-4 Plants that possess anticholinergic properties such as jimson weed, and street drugs cut with anticholinergics such as scopolamine are sources of accidental or intentional ingestion.1,2,4 Anticholinergic toxicity can cause a myriad of signs and symptoms, including agitation, seizures, hyperthermia, cardiac dysrhythmias, and death. Since poisoning from anticholinergic medications is frequently encountered in the emergency department, is it essential that emergency physicians be familiar with how to manage this toxidrome. This simulation case will allow the learner to evaluate and manage a patient presenting with anticholinergic toxicity.
By the end of this simulation case, learners will be able to: 1) describe the classic clinical presentation of anticholinergic toxicity, 2) discuss common medications and substances that may lead to anticholinergic toxicity, 3) recognize the electrocardiogram (ECG) findings in anticholinergic toxicity that require specific therapy, and 4) review the management of anticholinergic toxicity.
This simulation is taught using a high- or moderate-fidelity manikin.
The educational content was evaluated by the learners immediately after completion and debriefing of the scenario. This case was initially piloted with approximately twenty emergency medicine residents. The group was comprised of first, second-, and third-year residents from a three-year emergency medicine residency. The efficacy of the content was assessed by oral feedback.
Overall, the case was well received by learners, who felt it was useful and were engaged throughout the session. The overall feedback was positive and the case was well-received by learners.
This scenario was eventually tested on over 100 learners over the course of several years, and the overall feedback was positive. It was found to be effective when debriefing sessions using various debriefing techniques (such as advocacy/inquiry) were utilized to discuss both the learners' performance in the case, as well as the debriefing pearls (located at the end of this manuscript).
Anticholinergic toxicity, altered mental status, toxicology.
Objetivo: adaptar el Simulation Effectiveness Tool - Modified (SET-M) al portugués y verificar los índices de validez y confiabilidad. Método: estudio metodológico. En esta etapa de la investigación ...se utilizó el ISPOR, Análisis Factorial Confirmatorio, correlación entre el instrumento adaptado/Escala de Design de la Simulación - Versión Estudiante/Evaluación Práctica Individual y confiabilidad (test-retest e índices de consistencia interna). Muestra de conveniencia con 435 estudiantes de licenciatura en Enfermería y del posgrado. Resultados: el Simulation Effectiveness Tool – Modified - Versión Brasileña obtuvo un puntaje promedio entre 2,36 a 2,94; el Análisis Factorial Confirmatorio mostró una carga factorial > 0,30 para 17 de los 19 ítems. El alpha de Cronbach osciló entre 0,729 y 0,874; El omega de McDonald fue 0,782. No hubo correlación entre Simulation Effectiveness Tool – Modified Versión Brasileña y el Design de la Simulación o la Evaluación Práctica Individual. Hubo una correlación positiva entre el Simulation Effectiveness Tool – Modified Versión Brasileña y la edad de los participantes. Los puntajes de los voluntarios en las simulaciones fueron significativamente más altos que las de los observadores en tres dominios. Conclusión: el SET-M Versión Brasileña, manteniendo los 19 ítems y cuatro dominios de la escala original, se puso a disposición para su uso en Brasil para evaluar la efectividad de la simulación, recomendándose estudios con diferentes muestras.
Objetivo: adaptar para a língua portuguesa o Simulation Effectiveness Tool - Modified (SET-M) e verificar índices de validade e confiabilidade. Método: estudo metodológico. Utilizou-se o ISPOR, ...Análise Fatorial Confirmatória, correlação entre o instrumento adaptado/Escala de Design da Simulação – Versão Estudante/Avaliação Prática Individual e confiabilidade (teste-reteste e índices de consistência interna). Amostra de conveniência com 435 estudantes da Graduação em Enfermagem e Pós-Graduação. Resultados: o Simulation Effectiveness Tool - Modified Versão Brasileira obteve média de escores entre 2,36 a 2,94. A Análise Fatorial Confirmatória mostrou carga fatoral > 0,30 para 17 dos 19 itens. O alfa de Cronbach variou entre 0,729 e 0,874. O ômega de McDonald foi 0,782. Não houve correlação entre Simulation Effectiveness Tool - Modified Versão Brasileira e o Design da Simulação ou a Avaliação Prática Individual. Houve correlação positiva entre o Simulation Effectiveness Tool - Modified Versão Brasileira e a idade dos participantes. Os escores dos voluntários nas simulações foram significativamente mais altos que os dos observadores em três domínios. Conclusão: o SET-M Versão Brasileira, mantendo os 19 itens e quatro domínios da escala original, ficou disponibilizado para ser usado no Brasil para avaliar a efetividade da simulação, recomendando-se estudos com amostras diferentes.
AudienceThe targeted audience for this simulation are emergency medicine providers, including residents as well as advanced practice providers, to properly educate on recognizing, diagnosing, and ...managing methemoglobinemia. IntroductionMethemoglobinemia is a blood disorder characterized by the presence of ferric form of hemoglobin in the blood. This form of hemoglobin can carry oxygen but is unable to release it effectively causing a range of symptoms including headache, dizziness, nausea, and cyanosis. It is rarely congenital and mostly caused by the exposure to oxidizing agents, such as local anesthetics and quinolones.1 Normally, oxygen can bind to hemoglobin while it is in the ferrous state (Fe2+). In cases of methemoglobinemia, the heme iron configuration is converted from ferrous (Fe2+) to ferric (Fe3+), making it unable to bind to oxygen. As a result, normal ferrous hemes experience an increased affinity for oxygen causing a leftward shift in the oxygen dissociation curve. This in turn causes functional anemia due to reduced oxygen carrying capacity.1 Methemoglobinemia can result from exposure to different medications as well as environmental factors and presents like other disease processes including chronic obstructive pulmonary disease exacerbations. Congenital methemoglobinemia due to cytochrome b5 reductase deficiency is very rare, but the actual incidence is not known. Increased frequency of disease has been found in Siberian Yakuts, Athabaskans, Eskimos, and Navajo.2 Although it is also an unusual occurrence, acquired methemoglobinemia is much more frequently encountered than the congenital form.1In a 10-year retrospective study looking at the incidence rate of topical anesthetic-induced methemoglobinemia, it was found that the overall prevalence was 0.035%. A major risk factor was hospitalization at the time of a procedure being performed. An increased risk was also seen with benzocaine-based anesthetics.3. Educational ObjectivesAt the end of this simulation case, participants should be able to: 1) recognize shortness of breath, cyanosis and respiratory distress, and the difference between all of them based on the clinical presentation 2) identify the underlying cause of the condition by conducting a thorough history and physical 3) know how to identify and treat methemoglobinemia by ordering necessary labs and interventions and understand the pathophysiology leading to methemoglobinemia 4) recognize patient's response to treatment and continue to reassess. Educational MethodsThis is a high-fidelity simulation case that allows participants to evaluate and treat methemoglobinemia in a safe environment. The case is followed by a debriefing and small group discussion to review patient care skills, medical knowledge, interpersonal communication, practice-based learning, and improvement. Research MethodsThe educational content and efficacy were evaluated by oral feedback and a debriefing session immediately after completion of the simulation. A 5-point Likert scale was sent out to participants pre-simulation and post-simulation. Questions on the survey included whether they felt confident in their ability to recognize methemoglobinemia, understood the physiology and causes of methemoglobinemia, and felt confident in their ability to treat methemoglobinemia. ResultsSixteen learners responded to the survey, consisting of EM residents and medical students. Post simulation, approximately 92% of EM residents answered agree or strongly agree in their ability to recognize and treat methemoglobinemia compared to pre-sim survey of about 62.5%. Post-simulation feedback also resulted in positive reception, and learners found it useful to run through an uncommonly seen case in the hospital. Results showed overall improvement in recognition and treatment of methemoglobinemia among residents and medical students. DiscussionThis simulation improved recognition of methemoglobinemia including signs and symptoms associated with it. Proper management and treatment options were included such as administration of methylene blue. Overall, this simulation was helpful in teaching EM residents how to recognize, manage, and treat methemoglobinemia. In addition, post-simulation debriefing allowed further discussion among residents, which they found valuable. TopicsMethemoglobinemia, shortness of breath, cyanosis, respiratory distress, anemia, methemoglobin, oxygen dissociation curve, emergency medicine simulation.
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.
Generative social science Epstein, Joshua M; Epstein, Joshua M
2011., 20120102, 2012, 2007, 2007-01-01, 20060101, Letnik:
21
eBook
Agent-based computational modeling is changing the face of social science. In Generative Social Science, Joshua Epstein argues that this powerful, novel technique permits the social sciences to meet ...a fundamentally new standard of explanation, in which one "grows" the phenomenon of interest in an artificial society of interacting agents: heterogeneous, boundedly rational actors, represented as mathematical or software objects. After elaborating this notion of generative explanation in a pair of overarching foundational chapters, Epstein illustrates it with examples chosen from such far-flung fields as archaeology, civil conflict, the evolution of norms, epidemiology, retirement economics, spatial games, and organizational adaptation. In elegant chapter preludes, he explains how these widely diverse modeling studies support his sweeping case for generative explanation.
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