Epistaxis With Warfarin Coagulopathy: An Adult Simulation Case for Residents.
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ABSTRACT:
SUBMITTER: Deibel J
PROVIDER: S-EPMC7331959 | biostudies-literature | 2020
REPOSITORIES: biostudies-literature
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Project description:IntroductionThis case was designed to be an interprofessional scenario to assist the learner in the approach to a patient with cardiac tamponade. This resource provides information and materials for a high-fidelity simulation scenario that is appropriate for learners at multiple levels. Each learner has the opportunity to interact with embedded patient actors. This scenario includes the opportunity to conduct a bedside echocardiogram and perform an ultrasound-guided pericardiocentesis.MethodsA 51-year-old female presents to the emergency department with a chief complaint of shortness of breath and with a history of cancer. Her shortness of breath evolves into tachypnea, hypoxia, altered mental status, hypotension, and shock. The physical assessment reveals hypotension, muffled heart tones, and jugular vein distension. One critical action requires the recognition of pericardial effusion on a bedside echocardiogram. The learner needs to interpret the ultrasound findings in conjunction with the physical exam findings to diagnose cardiac tamponade. An emergent ultrasound-guided pericardiocentesis is to be performed. Equipment needed includes a high-fidelity adult mannequin, the low-cost ultrasound pericardiocentesis model (or pericardocentesis model of choice), bedside ultrasound, the PowerPoint presentation containing imaging, and laboratory data.ResultsA survey was completed by 23 residents who participated in this simulation. Ninety-five percent of those responding felt that this simulation in conjunction with the debriefing was effective in managing a patient presenting with undifferentiated shortness of breath and pericardial tamponade.DiscussionThis case will be incorporated into the 3-year curriculum for our emergency medicine residency program and assist with evaluation of resident performance of pericardiocentesis.
| S-EPMC6464418 | biostudies-literature
Project description:IntroductionAcute respiratory distress syndrome (ARDS) is present in approximately 10% of ICU admissions and is associated with great morbidity and mortality. Prone ventilation has been shown to improve refractory hypoxemia and mortality in patients with ARDS.MethodsIn this simulation, a 70-year-old male had been transferred to the ICU for ARDS and was undergoing scheduled prone ventilation as part of his care when he experienced a cardiopulmonary arrest secondary to a tension pneumothorax. Learners demonstrated how to manage cardiac arrest in a prone patient and subsequently identified and treated the tension pneumothorax that was the cause of his initial arrest. This single-session simulation for internal medicine residents (PGY 1-PGY 4) utilized a prone mannequin connected to a ventilator in a high-fidelity simulation center. Following the simulation, facilitators led a team debriefing and reviewed key learning objectives.ResultsA total of 103 internal medicine residents participated in this simulation. Of those, 43 responded to a postsimulation survey. Forty-two of 43 agreed or strongly agreed that all learning objectives were met, that the simulation was appropriate for their level of training, and that their participation would be useful for their future practice.DiscussionWe designed this simulation to improve learners' familiarity with prone cardiopulmonary resuscitation and to enhance overall comfort with cardiac arrest management. Postsimulation survey results and debriefings revealed that the simulation was a valuable education opportunity, and learners felt that their participation in this simulation would be helpful in their future practice.
| S-EPMC7880259 | biostudies-literature
Project description:Introduction:Sepsis is a major cause of morbidity and mortality in medicine and is managed in ICUs daily. Critical care training is a vital part of anesthesiology residency, and understanding the presentation, management, and treatment of septic shock is fundamental to intraoperative patient care. Methods:This simulation involved a 58-year-old man undergoing surgical debridement of a peripancreatic cyst with hemodynamic instability and septic shock. We conducted the simulation yearly for clinical anesthesia year 2 residents (n = 26) in 1-hour sessions with three to five learners at a time. The simulation covered the six Anesthesiology Milestones related to sepsis and septic shock as outlined in the Anesthesiology Milestones Project. Results:To date, 155 anesthesiology residents have completed the simulation. Commonly missed critical actions included failure to recognize the need for invasive lines, provide appropriate volumes of fluid resuscitation, inquire about blood cultures and antibiotics, and recognize the need for the patient to remain intubated. Most participants could appropriately diagnose and treat intraoperative septic shock, but all had moments of action or inaction to discuss and improve upon, and all learned from this scenario. Discussion:Simulation is an optimal way to practice the more rare and life-threatening clinical events in medicine. Even though septic shock is commonly managed in the ICU, it is relatively uncommon for it to develop acutely in the OR. This simulation is an effective and educational way to discuss the most recent sepsis/septic shock definition and review evidence-based guidelines for treatment.
| S-EPMC7083602 | biostudies-literature
Project description:IntroductionOncologic emergencies are life-threatening and often require advanced team-management skills as well as a mastery of disease processes and therapeutic interventions. Simulation of an oncologic emergency case is a useful way to experience, reflect on, and practice these skills. This case involving a simulated patient in blast crisis was created as part of our Emergency Medicine (EM) Resident Simulation Curriculum at the Perelman School of Medicine at the University of Pennsylvania.MethodsThis case is based on an actual patient seen in our emergency department and highlights specific teaching points and potential pitfalls in treatment algorithms. It details a 40-year-old female with history of acute myeloid leukemia presenting with fatigue for 2 days, tachycardia, and labored breathing. The patient develops worsening respiratory distress if not intervened upon and progresses to pulseless electrical activity arrest. Lab work is notable for markedly elevated white blood cell count and acidosis. A SimMan or SimMan3G is required for the simulation. The associated debriefing materials are Included in this educational resource. Evaluation of learner performance is mapped to the EM Milestones.ResultsEighteen of the 20 (90%) EM residents that participated in this simulation, responded to the Likert-scale postsession survey. Of those who responded, 83% agreed or strongly agreed that the case was realistic and 89% agreed or strongly agreed that the case was useful.DiscussionThe simulation venue offers a unique opportunity to address team dynamics as well as provide a forum for didactic learning as it is often difficult to debrief a critical case while working in real-time patient care settings.
| S-EPMC6440397 | biostudies-literature
Project description:Introduction:Emergency physicians must be able to manage inappropriately firing defibrillators. Many physicians may not experience this high-risk, low-frequency patient presentation during residency. We created this simulation to increase residents' knowledge of basic defibrillator function and confidence in managing patients with malfunctioning defibrillators. Methods:Sixteen emergency medicine residents of all levels of training participated in this curriculum. The educational experience began with a lecture. Residents then managed the simulated patient encounter in groups of four. The patient was a 63-year-old male presenting after feeling his defibrillator fire. He was found to have a supraventricular tachycardia with an inappropriately firing defibrillator. Learners needed to recognize the inappropriately firing defibrillator, inactivate it with a magnet, and treat the arrhythmia. Implementation of this scenario required audiovisual equipment and a simulation room equipped with high-fidelity simulator, patient monitor, code cart, defibrillator, and pacemaker magnet. Learners completed pre- and postcourse surveys to assess changes in baseline knowledge of defibrillator function and self-reported confidence in managing these complicated patients. Results:After participating in this educational intervention, residents improved their performance on a 10-question quiz from a class mean of 60% to 84% (p < .001). Residents also exhibited an increase in self-reported confidence in managing patients with inappropriately firing defibrillators (p < .001) and in knowing when to place a magnet over a patient's defibrillator (p < .001). Discussion:Residents demonstrated increased knowledge of defibrillator function as well as increased confidence in managing patients with malfunctioning defibrillators after participating in this simulation experience.
| S-EPMC6415004 | biostudies-literature
Project description:IntroductionSeizures in the setting of isoniazid (abbreviated INH, from isonocotinylhydrazide) toxicity can be intractable and persistent despite treatment with the usual status epilepticus (SE) medications. If not recognized in a timely fashion, SE can lead to significant morbidity and mortality. This simulation scenario instructs emergency medicine and pediatric residents and fellows in any year of training on the principles and management strategies of approaching a pediatric patient with SE due to INH toxicity.MethodsThis scenario presents a 5-year-old pediatric patient brought into the emergency department after a witnessed seizure at home, another en route to the emergency department, and a third event in front of the medical provider. This scenario was designed to include one 15- to 20-minute group simulation session, followed by a 10- to 15-minute debriefing of the case. The simulation can be run with a minimum of two participants-one to play the role of physician and the other to play the case director or simulation operator. Also included are visual stimuli consisting of relevant lab results, imaging, and other diagnostic studies. Finally, an educational handout created for all simulation participants reviews important teaching points related to the case.ResultsTo date, 30 residents have participated in this simulation during one of the weekly conference days. In the postactivity survey reviews, residents have reaffirmed their appreciation for their simulation time and have requested more exposure.DiscussionSimulation scenarios are an ideal teaching tool for rare and life-threatening diseases, as medical trainees will have little to no prior applied experience with such conditions.
| S-EPMC6440414 | biostudies-literature
Project description:IntroductionIn-flight medical emergencies are common occurrences that require medical professionals to manage patients in an unfamiliar setting with limited resources. Emergency medicine (EM) residents should be well prepared to care for patients in unusual environments such as on an aircraft.MethodsWe developed a simulation case for EM residents featuring a 55-year-old male passenger who suffers a cardiac arrest secondary to a tension pneumothorax. We conducted this case eight times during a 5-hour block of scheduled simulation time. Participants included EM residents of all training levels from one residency program. We arranged the simulation lab as an airplane cabin, with rows of chairs representing airplane seats and a mannequin in a window seat as the patient. Residents were expected to manage cardiac arrest and perform needle thoracostomy on the patient. Residents also evaluated and treated a flight attendant with a near syncopal episode. Throughout the case, residents were expected to practice teamwork skills, including leadership, communication, situational awareness, and resource utilization. Participants were debriefed and completed voluntary anonymous evaluations of the session.ResultsSeventeen EM residents participated in the simulation. Overall, all 17 found the simulation to be a valuable educational experience. In addition, all agreed or strongly agreed that they felt more prepared to respond to an in-flight emergency after participating in the simulation.DiscussionThis simulation was determined to be a valuable part of EM resident education. The challenges presented and skills practiced in this in-flight medical emergency simulation case are transferable to other resource-limited environments.
| S-EPMC7449573 | biostudies-literature
Project description:IntroductionThis activity is designed for midlevel and senior anesthesia trainees to experience the complexities of one-lung ventilation in pediatrics in a high-fidelity simulated environment. With the use of video-assisted thoracoscopic surgery (VATS) becoming increasingly common in pediatrics, we identified this area as an opportunity for the development of a dedicated educational simulation activity.MethodsOur simulated patient is a 3-year-old girl with empyema presenting for decortication via VATS who subsequently develops hypoxemia. The main challenges for the trainee include airway selection and insertion, lung isolation with fiber optic confirmation, and management of hypoxemia in the setting of one-lung ventilation. A pediatric medical simulator suitable for practicing resuscitation is required, and a tracheobronchial tree model is highly desirable. Basic knowledge of thoracic and pediatric anesthesia is required, but specific experience with pediatric lung isolation is not.ResultsLearners who experienced the content of this simulation expressed a strong sentiment of value. All pilot trainees were surveyed and indicated they either agree or strongly agree (4 or 5, respectively, on a 5-point Likert scale) that "This simulation enhanced my understanding of how to select lung isolation devices for pediatric patients" and "This simulation enhanced my understanding of how to manage hypoxia in context in one-lung ventilation." Comments were overall positive, including "I am better prepared to manage pediatric one lung ventilation cases."DiscussionAt the University of Iowa, this activity is part of a core curriculum of simulation training that resident physicians in anesthesiology experience during their training. It functions as a tool for education, evaluation, and self-identification of weaknesses in the learner's knowledge base as it relates to the perioperative management of pediatric one-lung ventilation, as well as for reinforcing material learned in the classroom and operating room. Numerous anesthesiology residents and faculty have pilot-tested this simulation, and necessary modifications have been made based on their feedback.
| S-EPMC6464470 | biostudies-literature
Project description:IntroductionMDMA (3,4-methylenedioxymethamphetamine) is a popular drug of abuse associated with a variety of clinical manifestations. There are a number of life-threatening sequelae, including, but not limited to, agitated delirium, cardiac dysrhythmias, and hyperthermia. Similar to other substances that cause sympathomimetic toxidromes, MDMA also induces a syndrome of inappropriate antidiuretic hormone secretion-like state resulting in hyponatremia. The management of hyperthermia is of particular importance, as time to correction, particularly at temperatures greater than 106 °F, is directly associated with increased risk of morbidity and mortality.MethodsWe created a simulation-based intervention to address and improve clinical skills relating to the management of MDMA intoxication. The scenario used a simulated patient to teach emergency medicine residents how to properly diagnose sympathomimetic toxicity and manage resultant hyperthermia and hyponatremia with cooling measures and appropriate fluid administration. Learners participated in a debrief session and were given an anonymous survey to assess their perceived knowledge. The case was performed as part of monthly emergency medicine resident didactics.ResultsEighteen learners took part in the case, with a 100% response rate. All participants agreed that the scenario increased their knowledge of cooling methods in severe hyperthermia, particularly whole-body packing. Eighty-nine percent (n = 16) reported that the scenario changed their practice patterns.DiscussionThis simulated scenario requires minimal resources and can be instituted with emergency medicine residents from all levels of training. The scenario achieved its primary goal of improving residents' perceived knowledge of cooling measures in severe hyperthermia.
| S-EPMC7845472 | biostudies-literature
Project description:IntroductionIn a CICO (cannot intubate, cannot oxygenate) situation, anesthesiologists and acute care physicians must be able to perform an emergency surgical cricothyrotomy (front-of-neck airway procedure). CICOs are high-acuity situations with rare opportunities for safe practice. In COVID-19 airway management guidelines, bougie-assisted surgical cricothyrotomy is the recommended emergency strategy for CICO situations.MethodsWe designed a 4-hour procedural simulation workshop on surgical cricothyrotomy to train 16 medical residents. We provided prerequisite readings, a lecture, and a videotaped demonstration. Two clinical scenarios introduced deliberate practice on partial-task neck simulators and fresh human cadavers. We segmented an evidence-based procedure and asked participants to verbalize the five steps of the procedure on multiple occasions.ResultsThirty-two residents who participated in the workshops were surveyed, with a 97% response rate (16 of 16 from anesthesiology, 15 of 16 from emergency medicine). Participants commented positively on the workshop's authenticity, its structure, the quality of the feedback provided, and its perceived impact on improving skills in surgical cricothyrotomy. We analyzed narrative comments related to three domains: preparation for the procedure, performing the procedure, and maintaining the skills. Participants highlighted the importance of performing the procedure many times and mentioned the representativeness of fresh cadavers.DiscussionWe developed a surgical cricothyrotomy simulation workshop for anesthesiology and emergency medicine residents. Residents in the two specialities uniformly appreciated its format and content. We identified common pitfalls when executing the procedure and provided practical tips and material to facilitate implementation, in particular to face the COVID-19 pandemic.
| S-EPMC8015712 | biostudies-literature