Journal of education & teaching in emergency medicine最新文献

Audience: This simulation is intended for 4^th year medical students.

Introduction: Headache is the fifth most common chief complaint in the emergency room, and the vast majority are ultimately diagnosed as benign primary headaches.1,2 However, subarachnoid hemorrhage (SAH) is one of several critical diagnoses which can present as a headache. With a case fatality rate of up to 66.7% in some instances, SAH is considered a "can't miss" diagnosis.3Subarachnoid hemorrhage is classically associated with a thunderclap headache, one definition of which is a headache that reaches maximal intensity within one minute or less and reaches a seven out of ten in severity.1 Unfortunately, a thunderclap headache is not as sensitive nor specific for SAH as is often taught. In one study, only 50% of patients with an aneurysmal subarachnoid hemorrhage presented with a thunderclap headache and an additional 19% of SAH headache came on more gradually over the course of five minutes.4 A second study found that only 66% of SAH patients reported a thunderclap headache.2 Thunderclap headaches can also be associated with other intercranial pathology including intracerebral hemorrhage, cerebral venous thrombosis, cervical artery dissection, posterior reversible encephalopathy syndrome, meningitis, and temporal arteritis among others.1,2 In a large observational study, SAH accounted for 32% of the serious pathology cases identified in patients with a thunderclap headache. Even among the thunderclap headache cohort, however, 88% of patients ultimately had a benign diagnosis (compared to 93% of patients who did not report a thunderclap headache).2Additional signs and symptoms of SAH include seizures in 6-9% of patients, vomiting, neck pain and stiffness, visual disturbances, loss of consciousness, and focal cranial nerve or supratentorial deficits.1,5 A non-contrasted computer tomography (CT) of the head within six hours of headache onset can have a sensitivity of 98.7 to 100%; however, the sensitivity decreased to 86% at the 24-48 hour mark.1,6 A meta-analysis found a pooled six hour sensitivity of 1.0 and asserts that a head CT interpreted as negative by an attending radiologist effectively rules out SAH in neurologically intact patients with a defined onset of a thunderclap headache.6 Some guidelines in the United States still recommend shared decision making with the patient to choose between a Lumbar Puncture (LP), Computer Tomography Angiogram (CTA), or no further testing to rule out SAH in the case of a negative head CT.2 The more time that has elapsed between onset and CT imaging, the stronger the recommendation to pursue further testing. A negative head CT followed by a negative LP approaches 100% sensitivity for ruling out SAH, and a negative head CT with a negative CTA has a 99.4% probability of ruling out SAH.1,3 Thus it is an important learning point that if a headache has been ongoing for more than six hours a

Subtalar dislocations of the talonavicular and talocalcaneal joints are rare, accounting for approximately one percent of all dislocations.1 These dislocations are typically the result of a high energy mechanism and present a challenge during reduction attempts. We present the case of a male in his early 20's who presented to the emergency department after a motorcycle accident with right foot and ankle pain and obvious deformity. Emergent X-ray and immediate attempt at reduction are of utmost importance with these dislocations. After multiple failed attempts at reduction in the ED, this patient was taken to the operating room for an open reduction with podiatry. This case report reviews the pathophysiology and management of this rare injury including nerve blocks and reduction techniques.

Topics: Subtalar dislocation, trauma, podiatry, joint reduction, nerve blocks, local anesthesia.

This case report highlights an uncommon sequelae of chest wall trauma that should be evaluated for patients presenting with similar history and symptoms. A 60-year-old man presented to the emergency department (ED) with swelling, fever, and chest wall pain two days after an assault with blunt chest wall trauma. On exam, there was a suspected chest wall abscess, verified on computed tomography (CT) with associated displaced midsternal fracture. This patient was admitted for abscess incision and drainage. While uncommon, chest wall abscess formation is an important condition that should be considered as a differential diagnosis in any patient presenting with chest wall pain post blunt trauma. With few reported similar presentations in the literature, this case is an important addition in a likely underreported phenomenon that requires prompt evaluation and treatment.

Topics: Blunt chest trauma, chest wall abscess, sternal fracture complication.

Audience: This is a combined independent study and simulation session designed to teach and drill Mass Casualty Incident (MCI) Triage and is intended for emergency medicine residents at all levels.

Introduction: The training of emergency medicine residents to assume leadership roles in disaster response is important. However, lack of accepted specific educational goals on the national level leads to significant variability between residencies.

Educational objectives: The purpose of this session is to train EM residents in the use of the Simple Triage and Rapid Treatment (START) and pediatric JumpSTART algorithms for triage in mass casualty incidents (MCIs) using an asynchronous model. By the end of this small group session, learners will be able to: 1) describe START triage for adult MCI victims; 2) describe JumpSTART triage for pediatric MCI victims; 3) demonstrate the ability to apply the START and JumpSTART triage algorithms in a self-directed learning environment; 4) demonstrate the ability to apply the START and JumpSTART triage algorithms in a simulated mass casualty scenario under time constraints; and 5) demonstrate appropriate use of acute life-saving interventions as dictated by the START and JumpSTART triage algorithms in a high-pressure simulated environment.

Educational methods: This session utilizes an online independent study module that was created de novo for this specific purpose by the authors followed by a high-pressure in-person simulation session where learners practice applying the START triage model with multiple simulated patients under time constraint.

Research methods: Learner feedback was collected after completion of the session. Retention of learning objectives was tested at four months via multiple-choice quiz.

Results: The session was very well received by our residents, who appreciated the opportunity to practice applying START triage under pressure. The average score on the pretest was 49%. Response rates to the post-test were low, but residents scored an average of 73%, indicating a trend towards retention of learning objectives.

Discussion: Overall, the utilization of a de novo online learning module followed by simulation proved to be a well-received method of teaching MCI triage to emergency medicine residents. We consider this to be an effective way to train MCI Triage with minimal in-conference time utilization. We plan to implement this training annually to provide our residents with longitudinal reinforcement of this vital skill.

Topics: Mass casualty, MCI, triage, START triage, JumpSTART Triage, disaster, disaster preparedness, disaster curriculum, prehospital, EMS.

Audience: This small-group workshop is designed for pre-clinical medical students. The workshop can also be offered to other medical students looking to review first aid in the community setting.

Introduction: First aid training in medical students varies based on each student's previous experience. Because of this, medical students in their pre-clinical years have expressed a desire for further training in first aid.1 While most bystanders in an emergency situation do not have a medical background, medical students have received additional training that can provide the skillset to process and respond to emergency situations in a different capacity. Most medical schools have not adopted a universal curriculum in teaching medical students first aid.2 Incorporating first aid into a medical school curriculum can enhance medical students' confidence in emergent situations and lead to better outcomes for patients requiring immediate on-site care.

Educational objectives: The goal of this workshop was to improve the confidence of medical students in handling emergencies in the community with the use of first aid while also giving them a standard approach to emergencies using an airway, breathing, and circulation approach. The curriculum was evaluated through student-perceived self-efficacy and confidence in handling the provided scenarios, performance on relevant multiple choice questions, and general appeal of the first aid sessions. By the end of this workshop, students will be able to define the goals of "first aid" and first responder actions, describe clinical signs and symptoms suggestive of an airway, breathing, or circulation emergency in the setting of selected medical emergencies, and demonstrate immediate care steps in the setting of selected medical emergencies, specifically the Heimlich maneuver on adults and infants, direct pressure, wound packing, tourniquet application for external bleeding, epinephrine auto-injector administration, and the recovery position for obtunded or unconscious patients.

Educational methods: Small group activities were performed with a focus on case-based scenarios combined with hands-on instruction. The four scenarios were choking, seizure, anaphylaxis, and bleeding which were taught by an educator who was either faculty, an emergency medicine resident, or an upper-level medical student. Facilitators were provided an educational handout specific to their station to guide them through the teaching session. A PowerPoint presentation was also provided complete with supporting images and videos to share with the students each session.

Research methods: Students were asked to complete a pre-test and post-test survey to assess knowledge outcome, self-efficacy in first aid, and overall appeal of the workshop. The multiple-choice knowledge outcome data was scored for percent correct on each question as well as

Audience: Intern and junior emergency medicine residents.

Introduction: Abdominal pain and vaginal bleeding in the first trimester of pregnancy are common presentations to the emergency department (ED).1 Formal transvaginal ultrasound (TVUS) is considered the test of choice for evaluation of first trimester pregnancy due to its high sensitivity and specificity for identifying intrauterine and ectopic pregnancies.1 Additionally, TVUS can evaluate for various uterine and ovarian pathology as well as identify other non-gynecologic conditions and is within the scope of practice for the emergency physician.2 Given the emergent and time sensitive nature of certain obstetric and gynecologic conditions, formal transvaginal ultrasound imaging may not be feasible. A rapid assessment with transvaginal point-of-care ultrasound (TVPOCUS) can be utilized by emergency medicine physicians (EMP) to confirm intrauterine pregnancies (IUP) and identify any associated complications. There are multiple advantages to TVPOCUS including reduced cost and length of stay, patient satisfaction, and improved resource utilization.1,3 Additionally, multiple studies demonstrate that EMPs can learn this skill and perform TVPOCUS accurately and safely.1,3 Developing the skills and comfort with TVPOCUS in a simulation setting during residency is beneficial and can have important implications in future practice.

Educational objectives: By the end of the session, learners should be able to 1) recognize the clinical indications for transvaginal ultrasound in the ED, 2) practice the insertion, orientation, and sweeping motions used to perform a TVPOCUS study, 3) interpret transvaginal ultrasound images showing an IUP or alternative pathologies, and 4) understand proper barrier, disinfection, and storage techniques for endocavitary probes.

Educational methods: This session included three high-fidelity simulation cases that allowed participants to utilize TVPOCUS in a safe and conducive environment. There was a total of 32 emergency medicine (EM) residents who participated. The simulation sessions were divided into two separate rooms and included four learners for each session that actively managed the patient, for a total of 12 active participants. The 20 remaining residents were observers. Participants learned evidence-based indications, performance, and interpretation of transvaginal ultrasound. Three cases were reviewed and included IUP, ruptured ectopic pregnancy with hemorrhagic shock, and appendicitis in pregnancy. The cases were followed by a debriefing session and discussion regarding the evidence behind bedside transvaginal ultrasound, its incorporation into EM workflow, and practice-based learning.

Research methods: The educational content and efficacy were evaluated by oral feedback in a debriefing session after the workshop. Additionally, pre-simulation and post-si

Audience: This scenario was developed to educate emergency medicine residents on the diagnosis and management of two concurrent conditions: septic abortion and disseminated intravascular coagulation (DIC).

Introduction: Patients with an abortion (spontaneous or induced) of less than twenty weeks gestation may present with concurrent uterine infection, also known as septic abortion. One of the complications of septic abortion is DIC. Early management of both underlying etiology (septic abortion) and subsequent complications (DIC) is crucial to minimize morbidity and mortality.

Educational objectives: At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history including pregnancy history, medication use, and past medical history. 2) Develop a differential for fever and vaginal bleeding in a pregnant patient. 3) Discuss management of septic abortion, including empiric broad-spectrum antibiotics and obstetric consultation for source control with dilation and curettage (D&C). 4) Discuss expected laboratory findings of disseminated intravascular coagulation (DIC). 5) Discuss management of DIC, including identification of underlying etiology and supportive resuscitation with blood products. 6) Review the components of blood products. 7) Identify appropriate disposition of the patient to the intensive care unit (ICU).

Educational methods: This session was conducted using high-fidelity simulation followed by a debriefing session and discussion about the diagnosis, differential, and management of both septic abortion and DIC. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. In this technique, the facilitator described something they observed in the case, outlined their reasoning as a facilitator why this observation was important or why they had questions, and then asked the learners to share their frame of reference at the time. An example: "I heard the team leader state that the platelets were normal, but then another resident disagreed. No one paused to come to a consensus. I'm wondering why this wasn't explored further in real time. Tell me more." This scenario may also be run as an oral boards case or adapted for other learners such as critical care fellows.

Research methods: Our residents were provided a survey at the completion of the debriefing session so they could rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form,1 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7.

Results: Thirteen learners completed

Audience: This simulation case was created for emergency medicine (EM) residents at all levels of training.

Background: Cardiac electrical storm (ES) is commonly defined as three or more episodes of sustained ventricular tachycardia, ventricular fibrillation, or three shocks from an implantable defibrillator within a 24 hour period.1 This can occur in up to 30-40% of patients with implantable defibrillators; however, it may also present in a wide variety of patients, including those with structural heart disease, myocardial infarction, electrolyte disturbances, and channelopathies.2,3 With each subsequent episode of ventricular arrhythmia, the arrhythmogenic potential of the heart may increase secondary to increased intracellular calcium dysregulation, myocardial injury, and increased endogenous release of catecholamines. The increased pain and catecholamine release from cardioversion/defibrillation and exogenous epinephrine during cardiac arrest further exacerbates ES.2 This carries a significant mortality risk of up to 12% in the first 48 hours.3This case involves a basic knowledge of the Advanced Cardiac Life Support (ACLS) for ventricular tachycardia, both with and without a pulse, and the application of Sgarbossa criteria in a patient with an ST elevation myocardial infarction (STEMI) which makes it ideal for the PGY-1. However, the case quickly becomes refractory to the basic management prescribed in ACLS, requiring trouble shooting and quick thinking about deeper pathophysiology, a skill that is crucial for all emergency medicine physicians. There are multiple ways to troubleshoot this case, making for a good variety of discussion and recent literature review on the complexities of a relatively common arrhythmia, ventricular tachycardia.

Educational objectives: By the end of this simulation, learners should be able to: 1) recognize unstable ventricular tachycardia and initiate ACLS protocol, 2) practice dynamic decision making by switching between various ACLS algorithms, 3) create a thoughtful approach for further management of refractory ventricular tachycardia, 4) interpret electrocardiogram (ECG) with ST-segment elevation (STE) and left bundle branch block (LBBB), 5) appropriately disposition the patient and provide care after return of spontaneous circulation (ROSC), 6) navigate a difficult conversation with the patient's husband when she reveals that the patient's wishes were to not be resuscitated.

Educational methods: This simulation was performed using high-fidelity simulation followed by an immediate debriefing with nine learners who directly participated in the SIM and twenty-three residents, who were online observers via Zoom. This case was done during our conference day, and there were a total of approximately forty total learners comprised of medical students, PGY-1, PGY-2 and PGY-3 residents. There were several medical students who also

Uterine perforation is a rare but potentially life-threatening complication of gynecologic procedures. Serious complications include hemorrhage, infection, and injury to surrounding organ systems (eg, gastrointestinal, urological, vascular, etc.). Risk factors include advanced maternal age, prior gynecologic surgeries, and other anatomical features that impact the difficulty of accessing the uterine cavity. In this case report, we discuss a patient who presented to the emergency department (ED) with diffuse abdominal pain and vaginal bleeding that occurred after an elective dilation and curettage (D&C) for a termination of pregnancy. The diagnosis was suspected clinically and confirmed by imaging including ultrasound (US) and computed tomography (CT) of the abdomen and pelvis. The patient was managed operatively with a multidisciplinary approach including Gynecology, General Surgery, and Urology. The patient was stabilized and eventually discharged. Uterine perforation should be included in the differential for patients with a history of recent gynecologic instrumentation presenting with abdominal pain and vaginal bleeding. The stabilization of these patients requires aggressive volume resuscitation, controlling the source of bleeding, and emergent surgical consultation.

Topics: Gynecology, vaginal bleeding, ultrasound, computed tomography.

Audience: This airway trainer modification is designed to instruct all levels of training in emergency medicine in order to familiarize trainees with airway anatomy and obtain superior views of the glottic inlet.

Introduction: During intubation with a standard geometry laryngoscope, such as the Macintosh blade, placement of the distal end of the blade within the vallecula and engagement of the median glossoepiglottic fold, also referred to as the midline vallecular fold (MVF), has long been championed by experts in airway management for its ability to improve glottic inlet visualization. This notion was further supported by the recent publication of a retrospective video review by Driver et al.1 Unfortunately, airway anatomy, including engagement of the MVF, does not receive the emphasis it deserves during intubation training of emergency medicine residents. Emergency physicians often have limited time to perform complete airway examinations, but a sound recognition and appreciation of the laryngeal inlet can serve as a roadmap to optimal laryngoscopy.2Recent advancements in airway education emphasize visualization of airway anatomy with review of video laryngoscopy (VL) recordings to identify routine VL errors in vallecula manipulation, such as failure to engage the MVF. 3 Simulation can continue to play an essential role in enhancing trainees' airway skills. Current airway trainers lack functional fidelity components, such an engageable MVF, resulting in a missed opportunity to teach airway skills and anatomy in a safe and controlled setting.4, 5 To address these concerns, we modified an existing airway task trainer with the addition of a simulated MVF to expose trainees to airway anatomy and adequate MVF engagement resulting in epiglottic elevation.

Educational objectives: By the end of this education session, participants should be able to:Identify relevant airway anatomy during intubation, including base of the tongue, epiglottis, midline vallecular fold, anterior arytenoids.Appreciate the value of a stepwise anatomically guided approach to intubation.Become familiar with the midline vallecular fold and underlying anatomy, including the hyoepiglottic ligament, and how proper placement of the laryngoscope can result in improved glottic visualization.

Educational methods: The TrueCorp AirSim airway task trainer was modified with the addition of a simulated MVF. Prior to the modification described here, there were no dynamic trainers with the functional fidelity needed to teach trainees how to engage the MVF with proper placement of the distal tip of the laryngoscope. Once the trainer was created, learners are introduced to relevant anatomy through the initial lecture to unsure baseline knowledge. During the lecture, videos and images are reviewed to demonstrate the importance of an anatomical roadmap to successful intubation. Learners then practiced with t