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.
Tracheoinnominate Artery Fistula Tarver, Emily M; Lerant, Anna A; Orledge, Jeffrey D ...
Journal of education & teaching in emergency medicine,
07/2021, Volume:
6, Issue:
3
Journal Article
Peer reviewed
Open access
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.
"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.
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.
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.
AudienceEmergency medicine residents of all levels. IntroductionPosterior reversible encephalopathy syndrome (PRES) is a clinically significant cause of seizures, headache, neurologic deficit, and ...hypertensive emergency that is not uncommon in the emergency department. Posterior reversible encephalopathy syndrome was initially described as a clinical syndrome in 1996.1 It is an important cause of hypertensive emergency that is not often covered in depth in the emergency medicine curriculum since the true incidence and disease process continues to be researched.Populations who are at most risk for PRES include those with chronic hypertension, chronic renal disease, autoimmune disease, and immune suppression.2 Patients with PRES will often present with varied forms of encephalopathy and sometimes even focal neurologic symptoms that would suggest a cerebral vascular accident. These neurologic symptoms can include visual complaints and headache. Seizures are also frequently reported in association with PRES.3Early identification and appropriate management of PRES decreases morbidity and mortality without chronic neurologic sequelae. The pillars of diagnosis and management can be initiated in the emergency department. This includes a diagnosis made by a thorough history and physical exam and cerebral imaging.4 The mainstay of management is parenteral anti-hypertensives with proper blood pressure monitoring.5. Educational ObjectivesBy the end of the simulation, the learner will be able to: 1) manage an acute seizure 2) discuss imaging modalities to diagnose PRES 3) discuss medical management of PRES. Educational MethodsThis simulation exercise is meant to be presented as a traditional medium-to-high-fidelity medical simulation case. With minor adjustments, it could be utilized as a low-fidelity case or an oral exam case. Research MethodsThe educational content and general usefulness of this simulation was evaluated by open verbal (qualitative) feedback from a convenience sample of random participants following a completion of the case and debriefing by a participant group (n=30) of emergency medicine residents at a large 3-year residency training program. ResultsThe overall feedback was positive. Participants felt that it was a good opportunity to practice identifying PRES and managing it in a safe learning environment. They especially appreciated learning more about the pathophysiology of PRES, the high-risk factors for PRES, and management of the condition. DiscussionPosterior reversible encephalopathy syndrome, an uncommon condition, presents similar to many other benign and common complaints. It is crucial to be able to differentiate PRES from other causes of headache, visual disturbance, and seizures. It is important to keep PRES in mind when considering hypertensive emergencies. Many PGY-1 residents struggled to diagnose and treat PRES because it was often not on their differential, and this case helped broaden their differential. PGY-2 and PGY-3 were more frequently able to appropriately diagnose and treat PRES in this patient but found the case to be helpful in their decision-making and learning more about PRES pathophysiology. This case and associated high-yield debriefing session were effective for learners of all levels. TopicsPosterior reversible encephalopathy syndrome (PRES), altered mental status, seizure, headache, hypertensive emergency.
AudienceThe aim of this simulation is to educate emergency medicine interns, residents and advanced providers on the recognition, diagnosis, and management of heparin-induced thrombocytopenia (HIT). ...Communication, teamwork, and crisis resource management are incorporated into the case. IntroductionHeparin-induced thrombocytopenia is a life-threatening complication of heparin exposure (eg, unfractionated heparin, low molecular weight LMW heparin) that occurs in a small percentage of patients exposed.1 It results in a consumptive coagulopathy in which the clotting cascade is inappropriately activated, leading to a low platelet count yet hypercoagulable state. HIT is associated with mortality rates of 20-30%, with a similar percentage of patients becoming subsequently disabled due to severe complications including limb amputation, multi-system organ failure, stroke or other causes of morbidity.2 Heparin-induced thrombocytopenia often presents 5 to 15 days after starting heparin treatment, and with more outpatients being treated with heparin products, it is likely that a first-line provider, such as an emergency medicine physician, would be the first clinician to encounter these patients. The combination of thrombocytopenia and hypercoagulability, along with the rarity of the disease, can make this difficult to diagnose and puts the first line clinician at risk for mismanagement. It is important to be familiar with the signs and symptoms of HIT and to refrain from starting heparin or platelets upon discovery of thrombosis or thrombocytopenia because it will lead to severe and rapid patient deterioration. Therefore, the ability to quickly recognize and treat this condition properly is an essential skill for emergency medicine physicians. Our goal is to create a simulated case that familiarizes emergency providers to this condition so they can be comfortable diagnosing and managing it in a real clinical scenario. Educational ObjectivesAfter completing this simulated case, participants will be able to: Obtain a detailed history that includes recent medications, medical, surgical, and social history to evaluate for HIT risk factors.Perform an adequate neurovascular exam including evaluation of motor function, sensation, skin color, pulses, and capillary refill.Order appropriate laboratory testing and imaging for diagnosis of thrombocytopenia and arterial occlusion, including bed side doppler or ultrasound.Discuss and recognize the symptoms of HIT and the contraindications of platelet and heparin administration in the emergency department.Avoid administration of heparin in the emergency department setting and recognize that platelets may worsen thrombus formation and lead to limb amputation.2Select appropriate medications for treatment and determine appropriate disposition for a patient presenting with HIT.Demonstrate interpersonal communication with patient and family.Recognize that HIT with thrombosis is a potential complication in hospitalized patients and outpatient settings and is associated with high mortality rates. Educational MethodsThis is a high-fidelity simulation case that allows participants to diagnose and treat HIT in a safe environment. The case is followed by a debriefing and small group discussion to review patient care skills, medical knowledge, interpersonal communication, and 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. Participants were provided with an evaluation at the completion of the debriefing session to provide qualitative feedback on the simulation case. A quality Likert Scale was used for the evaluation. ResultsPost-simulation feedback resulted in positive reception, and learners found it useful to run through a high-risk case potentially seen in the emergency department. Out of the 21 participants, 14 responded to the evaluation. Feedback was overwhelmingly positive with the majority rating the simulation as excellent or good.Discussion: The simulation improved awareness of the symptoms of HIT and contraindications of immediate platelet and/or heparin initiation upon vessel occlusion and thrombocytopenia discovery.Topics: Heparin-induced thrombocytopenia, pain control, resuscitation efforts, coagulation disorders, history taking, undifferentiated patient, arterial occlusion, hematology, emergency medicine simulation.
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