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.
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.
Eclampsia Yang, Thomas J; Sangal, Rohit B; Conlon, Lauren W
Journal of education & teaching in emergency medicine,
07/2021, Letnik:
6, Številka:
3
Journal Article
Recenzirano
Odprti dostop
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, Letnik:
6, Številka:
3
Journal Article
Recenzirano
Odprti dostop
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.
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.
"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.
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.
Pourtant, des études soulignent, chez la plupart des infirmières nouvellement diplômées, un déficit quant au niveau du jugement clinique requis pour prendre en charge des situations complexes, ...c'est-à-dire des situations imprévisibles et instables (Kavanagh et Szweda, 2017; Lasater et al., 2015; Monagle et al., 2018; Parker et al., 2014). Il fournit à l'apprenante l'information nécessaire pour s'améliorer. Ces instruments sont aussi nécessaires pour évaluer l'efficacité pédagogique des activités de simulation. Elle offre l'avantage de profiter des connaissances obtenues par des recherches effectuées avec la version originale de l'outil et de permettre des comparaisons de nature internationale (Haccoun, 1987; Hébert et al., 1994; Sousa et Rojjanasrirat, 2011; Vallerand, 1989). Méthode Le processus de la traduction et de la validation transculturelle d'un instrument doit suivre des règles précises et rigoureuses afin d'assurer l'équivalence entre l'instrument source et celui traduit (Hébert et al., 1994; Sousa et Rojjanasrirat, 2011; Vallerand, 1989). En d'autres mots, cela permet de trouver un terrain commun par rapport à une nomenclature applicable dans différentes régions, dans notre cas la francophonie. Tous sont en langue anglaise et plus de la moitié portent sur le jugement clinique, ses composantes (p. ex. travail en équipe, évaluation, communication) ou ses variantes (p. ex. pensée critique, raisonnement clinique.) Parmi ces derniers, le Lasater Clinical Judgment Rubric (LCJR) s'est avéré un instrument de mesure approprié pour apprécier le développement du jugement clinique dans des contextes de formation par simulation (Adamson et al., 2012; Cato et al., 2009; Lasater, 2007a, 2007b, 2011; Shin et al., 2015; Sideras, 2007). Basé sur le modèle du jugement clinique de Tanner (2006) et à partir de données empiriques recueillies lors de simulations, Lasater (2007a) a conçu une grille décrivant le jugement clinique en différents niveaux de performance : beginning, developing, accomplished et exemplary. Une grille est utile autant pour l'enseignante que pour l'étudiante (Arter et Chappuis, 2006). D'une part, elle définit de façon transparente les cibles d'apprentissages complexes et des attentes et assure une appréciation cohérente dans le temps, entre activités d'apprentissage et entre enseignantes. D'autre part, elle oriente les étudiantes pour qu'elles puissent comprendre les attentes à différents moments de leur formation. La grille LCJR a été conçue pour apprécier la trajectoire du développement du jugement clinique de l'étudiante selon une perspective longitudinale, au travers de son cheminement dans un programme de formation. Ces aspects trouvent leurs sources dans les fondements du cadre conceptuel du Tanner Clinical Judgment Model (Tanner, 2006). La grille comprend 11 indicateurs de performance clinique (Clinical Performance Indicators) : 3 pour l'aspect remarquer, 2 pour l'aspect interpréter, 4 pour l'aspect intervenir, et 2 pour l'aspect réfléchir. Une échelle à quatre niveaux (débutante (beginning), en développement \developing\, accomplie ^accomplished), exemplaire exemp/rz/y) permet de qualifier et de quantifier le degré de développement associé aux indicateurs de performance du jugement clinique. Sur le plan quantitatif, pour 11 indicateurs et quatre niveaux, un résultat faible correspond à 11 et un résultat élevé à 44 sur un total de 44 points. Ces versions ont ensuite été révisées par deux des chercheuses pour en produire une seule. Cela a pour but de maximiser le respect de la signification et de l'intention à l'origine des termes.
We introduce a novel differentiable hybrid traffic simulator, which simulates traffic using a hybrid model of both macroscopic and microscopic models and can be directly integrated into a neural ...network for traffic control and flow optimization. This is the first differentiable traffic simulator for macroscopic and hybrid models that can compute gradients for traffic states across time steps and inhomogeneous lanes. To compute the gradient flow between two types of traffic models in a hybrid framework, we present a novel intermediate conversion component that bridges the lanes in a differentiable manner as well. We also show that we can use analytical gradients to accelerate the overall process and enhance scalability. Thanks to these gradients, our simulator can provide more efficient and scalable solutions for complex learning and control problems posed in traffic engineering than other existing algorithms. Refer to https://sites.google.com/umd.edu/diff-hybrid-traffic-sim for our project.
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