AudienceEmergency medicine and pediatric residents, and pediatric emergency medicine (PEM) fellows. IntroductionBotulism is a rare but serious cause of infant hypotonia, vomiting, and respiratory ...failure. The differential diagnosis and management of a hypotonic infant with progressive weakness leading to respiratory failure is a rare presentation with high morbidity and mortality.1 Infants with botulism generally present with vague complaints that progressively worsen over time.2 Recognition of descending paralysis in an infant as well as signs of respiratory failure are key to preventing an adverse outcome. A key component of botulism treatment is recognizing the need to mobilize local resources to obtain BabyBIG® (botulism immune globulin). This process can and should begin in the emergency department. Educational ObjectivesAfter this simulation learners should be able to: 1) develop a differential diagnosis for the hypotonic infant, 2) recognize signs and symptoms of infant botulism, 3) recognize respiratory failure and secure the airway with appropriate rapid sequence intubation (RSI) medications, 4) initiate definitive treatment of infant botulism by mobilizing resources to obtain antitoxin, 5) continue supportive management and admit the patient to the pediatric intensive care unit (PICU), 6) understand the pathophysiology and epidemiology of infant botulism, 7) develop communication and leadership skills when evaluating and managing critically ill infants. Educational MethodsThis simulation case was performed using a high-fidelity Laerdal SimBaby with intubating capabilities and real-time vital sign monitoring. Additionally, this case can be performed with low fidelity manikins with supplemental scripting and visual stimuli. With minor adjustments, this case could be modified into an oral boards case. Research MethodsWe obtained feedback from a convenience sample of random participants after the simulation case and debrief were completed. The sample of emergency medicine residents (N=21) and PEM fellow (N=1) completed 5 questions on a 5-point Likert scale. ResultsThe emergency medicine residents and PEM fellow had mostly favorable feedback regarding the simulation and debriefing. Most strongly agreed or agreed that this would improve their performance in an actual clinical setting. DiscussionInfant botulism is a rare condition, presenting as vague non-specific complaints that worsen over time. It is important to differentiate infant botulism from other causes of weakness, hypotonia, and respiratory failure. This case presents learners with a high acuity, rare case of infant botulism and allows them to work through a complex pediatric patient encounter in a psychologically safe space. The presence of a standardized patient to play the patient's parent is key to assess learners' nontechnical communication skills and to increase fidelity during the simulation. TopicsInfant botulism, pediatric emergency medicine, respiratory failure, hypotonia, toxicology.
Breaking Bad News in the Emergency Department Siraco, Susan; Bitter, Cindy; Chen, Tina
Journal of education & teaching in emergency medicine,
04/2022, Letnik:
7, Številka:
2
Journal Article
Recenzirano
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AudienceThe primary audience for this simulation is emergency medicine (EM) residents, but this curriculum could also be used for EM-bound medical students. IntroductionBreaking bad news is a ...difficult but necessary skill for EM physicians. Bad news can range from informing family that a patient is in the emergency department (ED), to shared decision making regarding a life-threatening situation, to family notification of patient death.1 Although there are many structured approaches to death notification and breaking bad news, such as GRIEV_ING2 and SPIKES,3 EM physicians often lack confidence in their ability to effectively communicate bad news.1,4-6 Goals of care discussions and shared decision making become especially complex in the ED environment because critically ill patients often arrive without advanced directives, lack pre-existing rapport with the EM physician, and may require rapid engagement with surrogate decision-makers on emergent interventions.7 This simulation curriculum was developed to provide EM trainees with a psychologically safe environment to practice effective communication in breaking bad news, incorporating clinical scenarios commonly encountered in the ED. Educational ObjectivesAt the conclusion of these two simulation cases, learners will be able to 1) recognize signs of poor prognosis requiring emergent family notification, 2) take practical steps to contact family using available resources and personnel, 3) establish goals of care through effective family discussion, 4) use a structured approach, such as GRIEV_ING, to deliver bad news to patients' families, and 5) name the advantages of family-witnessed resuscitation. Educational MethodsThis curriculum consists of two simulation cases. Prior to the simulation, learners were assigned pre-reading on the GRIEV_ING approach to death notification, and how this approach could translate into breaking bad news in the ED. Although we chose to implement GRIEV_ING at our institution, other structured approaches (such as SPIKES) are reasonable as well. Each simulation case was conducted using a high-fidelity mannequin capable of intubation, respiratory examination findings such as abnormal breath sounds, and dynamic vital sign changes. Both cases required a standardized patient or other case confederate. Following each case, the learners underwent a debriefing session discussing how to break bad news in a high-pressure, time-sensitive ED environment. This case was designed as a high-fidelity simulation with a standardized patient, but it can be adapted to a low-fidelity simulation with a standardized patient. Research MethodsLearners filled out a survey before and after the simulation describing their confidence in establishing goals of care with patients and surrogates, notifying family members of bad news in the ED, and their use of a consistent approach to breaking bad news. Scores were analyzed using the related-samples Wilcoxon signed rank test. ResultsLearners exhibited improvement on all surveyed items, with statistically significant improvement on the survey item asking about their confidence in implementing a consistent approach to breaking bad news. Qualitative feedback was positive, with learners consistently endorsing the value of practicing difficult conversations in a simulated environment. First- and second-year residents appeared to benefit from the cases more strongly than senior residents. DiscussionThese cases provided a safe environment for learners to practice a structured approach to breaking bad news. Learners tended to aggressively resuscitate the elderly septic patient and perform invasive procedures, such as intubation and mechanical ventilation, prior to contacting family or establishing goals of care, which generated good discussion points during debriefing. TopicsSimulation, breaking bad news, goals of care discussion, death notification, sepsis, cardiac arrest, family witnessed resuscitation.
Lightning Strike Powell, Thomas; Charnigo, Aubri; Yee, Jennifer
Journal of education & teaching in emergency medicine,
04/2022, Letnik:
7, Številka:
2
Journal Article
Recenzirano
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AudienceThis scenario was developed to educate emergency medicine residents on the various presentations and management of a patient struck by lightning. IntroductionAnnually, there are approximately ...1.4 billon lightning strikes around the world; of these, an estimated 24,000 strikes cause significant injury or death.1 In the United States, there are approximately 400 lightning-related injuries every year resulting in 40 average annual deaths.1 Although only one in approximately 14,000 people will ever be struck by lightning, this still represents a significant injury mechanism for which emergency department providers must be prepared.2 Lightning is formed by static electricity built up due to ice crystals in clouds which creates a differential charge between the cloud and another object, such as the ground. Approximately one in every five lightning strikes is a cloud-to-ground strike which can result in injury or death. Lightning current flows may be as high as 100,000 amperes; this is survived 90% of the time only because the strong current of the bolt is applied in a very small timeframe, limiting the amount of energy transferred.3 Even so, with such large amperages, substantial injuries or death are possible. Not limited to a single mechanism, lightning can harm people in a variety of ways, including a direct strike, side-splash, ground current or upward streamers from the ground, or cause blast-type injury.2 The large electric currents involved can generate non-perfusing cardiac rhythms resulting in death if the patient is not immediately resuscitated through cardiopulmonary resuscitation (CPR) techniques with respiratory support.2. Educational ObjectivesAt the conclusion of the simulation session, learners will be able to: 1) Describe how to evaluate for scene safety in an outdoor space during a thunderstorm, 2) Obtain a relevant focused physical examination of the lightning strike patient, 3) Describe the various manifestations of thermo-electric injury, 4) Discuss the management of the lightning strike patient, including treatment and disposition, 5) Outline the principles of reverse triage for lightning strike patients, and 6) Describe long-term complications of lightning strike injuries. Educational MethodsThis session was conducted using a simulation scenario with a mix of high-fidelity manikins and standardized patients followed by a debriefing session on the presentation, differential diagnosis, and management of lightning strike patients. 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 examination case. Research MethodsThe residents are provided a survey at the completion of the debriefing session to rate different aspects of the simulation, as well as to provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center. ResultsFeedback from the residents was overwhelmingly positive, although several learners struggled with identifying Lichtenberg figures and keraunoparalysis either due to the low-light setting, unfamiliarity of the pathology, or that the depictions were not as expected. The subsequent debriefings allowed for multiple areas of discussion. Debriefing topics included the comparing and contrasting low voltage/high voltage/lightning strike injuries, possible clinical presentations of the lightning strike patient, reverse triage principles, categorizing blast injuries, discussion of disposition, and the determination of prehospital scene safety.The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form4 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Thirty-one learners completed a feedback form. This session received all 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than one isolated 5 score. The statement, "Before the simulation, the instructor set the stage for an engaging learning experience," received the lowest average score with 6.81, while "The instructor structured the debriefing in an organized way" received an average score of 6.94.The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: "Absolutely loved this sim. Tested multiple aspects of massCal care. Communication, critical care, scene safety, etc., nailed it," and "Very engaging and fun with a lot (of) good debriefing." DiscussionThis is an easily reproducible method for reviewing management of the lightning strike patient. Faculty may choose to use a combination of high- or low-fidelity manikins, task trainers, standardized patients, or confederate actors/volunteers as patients. There are multiple potential presentations and complications of the lightning strike patient to further customize the experience for learners' needs. For those who are looking to scale down the scenario, victims may be limited to one or two individuals, using whatever preferred mixture of manikins or standardized patients is needed or desired. TopicsMedical simulation, lightning strike patient, thermo-electrical burn, wilderness first-aid, blast injuries, wilderness medicine, emergency medicine, austere medicine.
•A method for leveraging known physics, expressed in a PDE, to learn closures for missing physics.•Optimization of combined PDE-ML system with stochastic gradient descent, utilizing adjoint ...PDEs.•Complete demonstration for sub-filter-scale closure for large-eddy simulation (LES) of turbulence.•Outperforms common LES models.•Outperforms direct a priori learning of simple mismatch.
A framework is introduced that leverages known physics to reduce overfitting in machine learning for scientific applications. The partial differential equation (PDE) that expresses the physics is augmented with a neural network that uses available data to learn a description of the corresponding unknown or unrepresented physics. Training within this combined system corrects for missing, unknown, or erroneously represented physics, including discretization errors associated with the PDE's numerical solution. For optimization of the network within the PDE, an adjoint PDE is solved to provide high-dimensional gradients, and a stochastic adjoint method (SAM) further accelerates training. The approach is demonstrated for large-eddy simulation (LES) of turbulence. High-fidelity direct numerical simulations (DNS) of decaying isotropic turbulence provide the training data used to learn sub-filter-scale closures for the filtered Navier–Stokes equations. Out-of-sample comparisons show that the deep learning PDE method outperforms widely-used models, even for filter sizes so large that they become qualitatively incorrect. It also significantly outperforms the same neural network when a priori trained based on simple data mismatch, not accounting for the full PDE. Measures of discretization errors, which are well-known to be consequential in LES, point to the importance of the unified training formulation's design, which without modification corrects for them. For comparable accuracy, simulation runtime is significantly reduced. A relaxation of the typical discrete enforcement of the divergence-free constraint in the solver is also successful, instead allowing the DPM to approximately enforce incompressibility physics. Since the training loss function is not restricted to correspond directly to the closure to be learned, training can incorporate diverse data, including experimental data.
AudienceThis case is targeted to emergency medicine residents of all levels. IntroductionUpper gastrointestinal bleeding (UGIB) is a common chief complaint encountered in the emergency department, ...resulting in over 500,000 hospitalizations and 20,000 deaths annually in the United States.1 The diagnosis and management of UGIB in stable patients is typically fairly straightforward. However, there are a number of circumstances where the treatment of UGIB is much more challenging, and emergency medicine (EM) physicians should be familiar with, and have experience managing, these difficult presentations. Massive UGIB can necessitate the need for management of a difficult airway in the setting of airway contamination, as well as placement of a gastroesophageal balloon tamponade device. The appropriate use and indications for performing this high-risk/low-frequency procedure requires dedicated practice. Furthermore, the management of gastrointestinal hemorrhage in a patient with a religious objection to the administration of blood products, including Jehovah's Witnesses, can be especially challenging and requires knowledge of alternative therapies to support blood pressure, oxygen carrying capacity, and decrease coagulopathy.2,3. Educational ObjectivesBy the end of this simulation, learners will be able to: 1) manage a hypotensive patient with syncope and hematemesis, 2) pharmacologically manage an acute UGIB addressing the various causes, 3) recognize worsening clinical status and intervene by performing difficult airway management, 4) place a gastroesophageal balloon tamponade device. Educational MethodsThis simulation was conducted with a high-fidelity mannequin with a separate medium-fidelity intubating mannequin that was modified to allow rapid filling of the oropharynx with simulated blood. Due to the COVID-19 pandemic, a total of six EM residents in various levels of training participated in the simulated patient encounter while the rest of the learners watched the simulation and participated in the debrief via video conference. Research MethodsFollowing the simulation and debrief session, all the residents, including those who participated in-person and via video conference, were sent a survey via surveymonkey.com to assess the educational quality of the simulation. ResultsOverall residents expressed positive feedback on the scenario, noting that the case was realistic, appropriately complex, and improved their medical knowledge and procedural skills. DiscussionThis case has a mixture of high-fidelity and medium-fidelity components which can be easily reproduced. The case was extremely useful in teaching EM residents of all levels not only how to manage large volume UGIB in a patient who is also a Jehovah's Witness, but also how to manage the airway and place a gastroesophageal balloon tamponade device. The case starts with a patient presenting with syncope and as the case unfolds, the patient's clinical status deteriorates, requiring learners to resuscitate, intubate, and obtain a gastroesophageal balloon tamponade.Residents commented that managing this case of an UGIB was extremely challenging because it exposed and filled important gaps in both their knowledge and procedural skills. Residents struggled most with identifying alternative therapies to blood products in patients with religious objections, and the step-by-step process of placing a Blakemore tube. TopicsUpper gastrointestinal bleed, hemorrhagic shock, Jehovah's Witness, difficult airway.
Syncope Due to a Ruptured Ectopic Pregnancy Hunt, Derek Jc; McLendon, Kevin; Conrad, Jodi
Journal of education & teaching in emergency medicine,
01/2022, Letnik:
7, Številka:
1
Journal Article
Recenzirano
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AudienceThis simulation is intended for all levels of emergency medicine residents. IntroductionSyncope and near-syncope are very common presenting complaints to the emergency department.1 There are ...several causes of syncope ranging from benign to life threatening. It is imperative that the emergency physician is able to evaluate and treat patients with undifferentiated syncope even with limited information. Approximately half of syncope cases can be differentiated by the presentation and clinical context.1 In addition to a thorough history, an electrocardiogram (ECG) should be obtained on all patients presenting with syncope or near-syncope since it is non-invasive and cost effective in assessing cardiac causes of syncope. In this particular simulation, the cause of syncope is due to a hemorrhagic shock from a ruptured ectopic pregnancy. Educational ObjectivesAt the conclusion of this simulation, the learner will be able to:Review the initial management of syncopeUtilize laboratory and imaging techniques to diagnose a ruptured ectopic pregnancy.Demonstrate the ability to resuscitate and disposition an unstable ruptured ectopic pregnancy. Educational MethodsThis simulation case was designed as a medium-to-high fidelity simulation scenario. It could also be altered and utilized as a practice oral board exam case. Research MethodsThe quality of the simulation and educational content was evaluated by debriefing and verbal feedback that was obtained immediately after the case. Additionally, a survey was emailed to participants and observers of the case to provide qualitative feedback. ResultsPost-simulation feedback from learners and observers was positive. Everyone present for the simulation felt that it was realistic and provided a unique opportunity to practice resuscitation skills. DiscussionSyncope and near-syncope are common presentations to the emergency department with multiple etiologies that range from cardiac, neurologic, neurocardiogenic, and orthostatic to unknown. It is crucial that we diagnose and treat life-threatening causes of syncope rapidly and with limited information. In this case, the cause of syncope due to a ruptured ectopic pregnancy should be rapidly diagnosed with a thorough history and exam, urine pregnancy test, and a bedside abdominal ultrasound. Once the urine pregnancy test was resulted, ectopic pregnancy was the top differential diagnosis for each learner that participated. Initially, most learners only performed a transabdominal pelvic ultrasound of the pelvis, which is normal in the case. One learner performed a rapid ultrasound for shock and hypotension (RUSH) exam and was able to find free fluid in the right upper quadrant. Overall, this case and the debriefing topics were effective for learners at all levels. TopicsEctopic pregnancy, obstetrical emergencies, ultrasound, resuscitation.
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.
AudienceThe target audience of this simulation is emergency medicine residents and medical students. The simulation is based on a real case of a 13-year-old female who presented with seizures and ...hypoxia and was ultimately diagnosed with pulmonary embolism. The case highlights diagnosis and management of an adolescent with new onset seizures, deterioration in status, and treatment options in pediatric cardiac arrest due to pulmonary embolism. BackgroundPulmonary embolism (PE) is an uncommon cause of hypoxia in children making diagnosis difficult. A study looking at 23 years of admission and autopsy data on children found the incidence of clinically significant pulmonary embolism to be 25 per 100,000.1 However, when children present to the emergency department with hypoxia and altered mental status, a diagnosis of pulmonary embolism cannot be excluded. Risk factors such as use of estrogen containing oral contraceptives, immobilization, and recent surgery should raise suspicion for pulmonary embolism in the clinically deteriorating adolescent patient.2,3. Educational ObjectivesBy the end of the simulation, learners will be able to:1) develop a differential diagnosis for an adolescent presenting with hypoxia and seizure-like activity2) discuss the utility of bedside ultrasound in helping to differentiate causes of hypoxia3) discuss management of cardiac arrest due to PE in the pediatric patientSecondary learning objectives include:4) discuss indications for emergent use of thrombolytics and Extracorporeal Membrane Oxygenation (ECMO) while becoming aware of institution-based limitations5) demonstrate interpersonal communication with family, nursing, pharmacy, and consultants during high stress situations. Educational MethodsThis is a high-fidelity simulation that allows learners to manage the diagnosis and treatment of pulmonary embolism in an adolescent patient. Participants participated in a debriefing after the simulation.Research Methods:The effectiveness of this case was evaluated by surveys given to learners after debriefing. Learners gave quantitative and qualitative results of their feedback using a 1-5 rating scale and leaving written feedback. This case was performed with residents in their first and second years of training. ResultsFeedback was overall positive, with many of the residents giving the case high scores on effectiveness of the simulation in their education. They enjoyed the case and reported they would feel more comfortable in a comparable situation in the future. DiscussionPulmonary embolism is an uncommon but important diagnosis for emergency medicine physicians to consider in pediatric cardiac arrest. This case has multiple parts and was based on a real case in our emergency department in which a patient presenting with new seizure-like activity followed by cardiac arrest was ultimately diagnosed with a PE. The case was well received by our learners who felt it improved their identification of this diagnosis and its management. TopicsPulmonary embolism, oral contraceptives, altered mental status, pediatric, adolescent, cardiac arrest, ECMO, thrombolytic, hypoxia, emergency medicine, medical simulation.
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.
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