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.
Peripartum Cardiomyopathy Morris, Victoria L; Mendoza, Carolina; Stevens, Gowri S ...
Journal of education & teaching in emergency medicine,
04/2023, Volume:
8, Issue:
2
Journal Article
Peer reviewed
Open access
AudienceThis simulation is appropriate for emergency medicine (EM) residents of all levels. IntroductionPeripartum cardiomyopathy (PPCM) is a rare, idiopathic condition that occurs in the mother ...around the time of childbirth. Heart failure with reduced ejection fraction and/or reduced systolic function diagnosed in patients during the last month of pregnancy or up to five months following delivery defines PCCM.1 Another broader definition from the European Society of Cardiology defines PPCM as heart failure that occurs "towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found."2 Though PPCM occurs worldwide, most data is extracted from the United States (incidence 1:900 to 1:4000 live births), Nigeria, Haiti, and South Africa.3,4Risk factors for PPCM include pre-eclampsia, multiparity, and advanced maternal age. Unfortunately, the complete pathophysiology of PPCM remains unclear. However, it is important for emergency physicians to be aware of this rare diagnosis because though 50-80% of women with PPCM may eventually recover normal left ventricle systolic function,5 positive outcomes depend on timely recognition of PPCM as a disease and the appropriate management of heart failure. Symptomatic PPCM is an emergent condition that requires an attentive and knowledgeable emergency medicine physician for rapid recognition and treatment. A simulation of this rare condition can give residents the experience of identifying and managing this disease that they might not otherwise see personally during their training. Educational ObjectivesBy the end of this simulation session, learners will be able to: 1) initiate a workup of a pregnant patient who presents with syncope, 2) accurately diagnose peripartum cardiomyopathy, 3) demonstrate care of a gravid patient in respiratory distress due to peripartum cardiomyopathy, 4) appropriately manage cardiogenic shock due to peripartum cardiomyopathy. Educational MethodsThis simulation was conducted as a high-fidelity medical simulation case followed by a debriefing. It could potentially be adapted for use as a low-fidelity case or an oral boards exam case. Research MethodsThe educational content and clinical applicability of this simulation was evaluated by oral and written feedback from participant groups at a large three-year emergency medicine residency training program. Each participant completed the case and the facilitated debriefing afterwards. Case facilitators also provided their personal observations on the implementation of the simulation. ResultsThe participants gave the simulation positive feedback (n=18). Seventeen EM residents and one pediatric emergency medicine (PEM) fellow participated in the feedback survey. Learners overall agreed (18.75%) or strongly agreed (81.25%) that participating in this simulation would improve their performance in a live clinical setting. DiscussionPeripartum cardiomyopathy is a low frequency, high acuity illness that requires a synthesis of the learner's knowledge of complex physiology, navigation of logistical and systems-based challenges, and advanced communication and leadership skills to ensure the best possible patient outcome. All EM physicians will be expected to expertly manage this illness after completion of an EM training program, yet not every EM resident will encounter this type of patient during training. Supplementing the EM resident's standard training with this simulation experience provides a psychologically and educationally safe space to learn and possibly make mistakes without causing patient harm. Practically all residents were able to correctly diagnose the patient with a cardiomyopathy even if they were not familiar with the diagnosis of "peripartum cardiomyopathy." The residents particularly enjoyed the case to explore concepts of benefits and risks of medical therapeutics (ie, positive pressure ventilation, vasopressors/inotropes) and safe practice for the gravid patient. This case and the associated high yield debriefing session were effective teaching tools for emergency medicine residents about PPCM. TopicsMedical simulation, peripartum cardiomyopathy, pregnancy, respiratory failure, cardiogenic shock, emergent cesarian section.
Botulism due to Injection Drug Use Hoffman, Timothy; Yee, Jennifer
Journal of education & teaching in emergency medicine,
04/2023, Volume:
8, Issue:
2
Journal Article
Peer reviewed
Open access
AudienceThis scenario was developed to educate emergency medicine residents on the diagnosis and management of wound botulism secondary to injection drug use. IntroductionBotulism is a relatively ...rare cause of respiratory failure and descending weakness in the United States, caused by prevention of presynaptic acetylcholine release at the neuromuscular junction. This presentation has several mimics, including myasthenia gravis and the Miller-Fisher variant of Guillain-Barré. It may be caused by ingestion of spores (infant), ingestion of pre-formed toxin (food-borne), formation of toxin in vivo (wound-associated cases), through weaponized sources, or through inappropriately administered injections (iatrogenic). Cases of black tar heroin injection have been associated with botulism. Regardless of the etiology, prompt assessment and support of respiratory muscle strength and ordering antidotal therapy is key to halting further muscle weakness progression. Educational ObjectivesAt the conclusion of the simulation session, learners will be able to: 1) Identify the different etiologies of botulism, including wound, food-borne, infant, iatrogenic, and inhalational sources, 2) describe the pathophysiology of botulism toxicity and how it prevents presynaptic acetylcholine release at the neuromuscular junction, 3) develop a differential for bilateral descending muscle weakness, 4) compare and contrast presentations of myasthenia gravis, botulism, and the Miller-Fisher variant of Guillain-Barré syndrome, 5) describe measurement of neurologic respiratory parameter testing, such as negative inspiratory force, 6) outline treatment principles of wound-associated botulism, including antitoxin administration, wound debridement, tetanus vaccination, and evaluation for the need of antibiotics, and 7) identify appropriate disposition of the patient to the medical intensive care unit (ICU). Educational MethodsThis session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of botulism secondary to injection drug use. 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. ResultsSixteen learners completed a feedback form. This session received all six and seven scores (consistently effective/very good and extremely effective/outstanding, respectively) other than three isolated five scores. The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: "Really awesome debrief, breakdown of pathophysiology and clinical applications. Great work!"; "Great case with awesome learning points," and "Loved this session. Rare case but very great learning." Specific scores are available upon request. DiscussionThis is a cost-effective method for reviewing botulism diagnosis and management. The case may be modified for appropriate audiences, such as using classic illness scripting (eg, ingestion of canned foods). We encourage readers to utilize a standardized patient to demonstrate extraocular muscle weakness and bulbar symptoms to increase psychological buy-in. TopicsMedical simulation, botulism, toxicologic emergencies, toxicology, neurology, emergency medicine.
Acute Exacerbation of COPD Pappas, Dominic; Vempati, Amrita
Journal of education & teaching in emergency medicine,
04/2023, Volume:
8, Issue:
2
Journal Article
Peer reviewed
Open access
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.
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.
How do you get students to engage in a historical episode or era? How do you bring the immediacy and contingency of history to life? Michael A. Barnhart shares the secret to his award-winning success ...in the classroom with Can You Beat Churchill?, which encourages role-playing for immersive teaching and learning. Combating the declining enrollment in humanities classes, this innovative approach reminds us how critical learning skills are transmitted to students: by reactivating their curiosity and problem-solving abilities. Barnhart provides advice and procedures, both for the use of off-the-shelf commercial simulations and for the instructor who wishes to custom design a simulation from scratch. These reenactments allow students to step into the past, requiring them to think and act in ways historical figures might have. Students must make crucial or dramatic decisions, though these decisions need not align with the historical record. In doing so, they learn, through action and strategic consideration, the impact of real individuals and groups of people on the course of history. There is a quiet revolution underway in how history is taught to undergraduates. Can You Beat Churchill? hopes to make it a noisy one.
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.
Intermolecular interactions stem from the electric properties of atoms. Being the cause of molecular aggregation, intermolecular forces are at the roots of chemistry and are the fabric of the world. ...They are responsible for the structure and properties of all condensed bodies — the human body, the food we eat, the clothes we wear, the drugs we take, the paper on which this book is printed. In the last forty years or so, theoretical and experimental research in this area has struggled to establish correlations between the structure of the constituent molecules, the structure of the resulting condensed phase, and the observable properties of any material. As in all scientific enterprise, the steps to follow are analysis, classification, and prediction, while the final goal is control; which in this case means the deliberate design of materials with specified properties. This last step requires a synthesis and substantial command of the three preceding steps. This book provides a brief but accurate summary of all the basic ideas, theories, methods, and conspicuous results of structure analysis and molecular modelling of the condensed phases of organic compounds: quantum chemistry, the intermolecular potential, force field and molecular dynamics methods, structural correlation, and thermodynamics. The book also exposes the present status of studies in the analysis, categorisation, prediction, and control, at a molecular level, of intermolecular interactions in liquids, solutions, mesophases, and crystals. The main focus here is on the links between energies, structures, and chemical or physical properties.
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.
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