Journal of education & teaching in emergency medicine最新文献

Audience: This suite of borescope laryngoscopes is designed to instruct emergency medicine residents and sub-interns in video-assisted airway management.

Background: Skillful and confident airway management is one of the markers of a strong emergency medicine physician.1 Video-assisted airway management is a necessary skill, particularly in the setting of difficult airways and cervical spine immobilization.2,3 However, the idea of learning airway management "by doing" is high-risk and mistakes can have devastating implications on patient outcomes. Fortunately, high-fidelity medical simulation tools have been developed to address this dilemma, allowing a safe environment for providers to practice their airway management skills.4,5 These tools, while undeniably useful, are limited in their scope; they are often designed for clinical rather than educational use, and are proprietary and expensive.6,7Video laryngoscopes approved for patient use are difficult to implement widely in educational settings due to cost or because they cannot be removed from a designated area. Clinical video laryngoscopy suites typically cost 2,000 - 6,000 US dollars. Additionally, the video images can only be viewed on a local small screen rather than a television or projector. This means that the number of learners is limited by space around the small laryngoscope screen. These cost and space barriers may be especially pronounced in low resource or non-traditional learning environments.

Educational objectives: Using an anatomically accurate airway simulator, by the end of a 20-30-minute instructional session, learners should be able to: 1) Understand proper positioning and use the video laryngoscope with dexterity, 2) identify airway landmarks via the video screen, and 3) demonstrate ability to intubate a simulated airway.

Educational methods: We developed a low-cost borescope laryngoscope for airway simulation training. Using this device, learners should be able to identify airway landmarks and successfully intubate a simulated airway. The borescope laryngoscope, a novel device which employs the camera-end of a video borescope and a single-use VL blade, was used by learners during high-fidelity airway simulation. Learners were residents or medical students undergoing airway training in case-based simulation, or in airway-management procedure stations.

Research methods: The borescope laryngoscopes were used during dedicated airway training in place of their medical device counterparts. During case-based simulation sessions involving airway management, 32 residents and 20 medical students used the borescope laryngoscope. During dedicated airway management procedure stations, 12 medical students used the borescope laryngoscope. Learners were instructed to perform endotracheal intubation and fully visualize critical structures before passing the tube. Successful int

Audience: This simulation is appropriate for emergency medicine (EM) residents of all levels.

Introduction: Peripartum cardiomyopathy (PPCM) is a rare, idiopathic condition that occurs in the mother around the time of childbirth. Heart failure with reduced ejection fraction and/or reduced systolic function diagnosed in patients during the last month of pregnancy or up to five months following delivery defines PCCM.1 Another broader definition from the European Society of Cardiology defines PPCM as heart failure that occurs "towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found."2 Though PPCM occurs worldwide, most data is extracted from the United States (incidence 1:900 to 1:4000 live births), Nigeria, Haiti, and South Africa.3,4Risk factors for PPCM include pre-eclampsia, multiparity, and advanced maternal age. Unfortunately, the complete pathophysiology of PPCM remains unclear. However, it is important for emergency physicians to be aware of this rare diagnosis because though 50-80% of women with PPCM may eventually recover normal left ventricle systolic function,5 positive outcomes depend on timely recognition of PPCM as a disease and the appropriate management of heart failure. Symptomatic PPCM is an emergent condition that requires an attentive and knowledgeable emergency medicine physician for rapid recognition and treatment. A simulation of this rare condition can give residents the experience of identifying and managing this disease that they might not otherwise see personally during their training.

Educational objectives: By the end of this simulation session, learners will be able to: 1) initiate a workup of a pregnant patient who presents with syncope, 2) accurately diagnose peripartum cardiomyopathy, 3) demonstrate care of a gravid patient in respiratory distress due to peripartum cardiomyopathy, 4) appropriately manage cardiogenic shock due to peripartum cardiomyopathy.

Educational methods: This simulation was conducted as a high-fidelity medical simulation case followed by a debriefing. It could potentially be adapted for use as a low-fidelity case or an oral boards exam case.

Research methods: The educational content and clinical applicability of this simulation was evaluated by oral and written feedback from participant groups at a large three-year emergency medicine residency training program. Each participant completed the case and the facilitated debriefing afterwards. Case facilitators also provided their personal observations on the implementation of the simulation.

Results: The participants gave the simulation positive feedback (n=18). Seventeen EM residents and one pediatric emergency medicine (PEM) fellow participated in the feedback survey. Learners overall agreed (18.75%) or strongly agreed (81.25%) that participating in this sim

Audience: This scenario was developed to educate emergency medicine residents on the diagnosis and management of wound botulism secondary to injection drug use.

Introduction: Botulism is a relatively rare cause of respiratory failure and descending weakness in the United States, caused by prevention of presynaptic acetylcholine release at the neuromuscular junction. This presentation has several mimics, including myasthenia gravis and the Miller-Fisher variant of Guillain-Barré. It may be caused by ingestion of spores (infant), ingestion of pre-formed toxin (food-borne), formation of toxin in vivo (wound-associated cases), through weaponized sources, or through inappropriately administered injections (iatrogenic). Cases of black tar heroin injection have been associated with botulism. Regardless of the etiology, prompt assessment and support of respiratory muscle strength and ordering antidotal therapy is key to halting further muscle weakness progression.

Educational objectives: At the conclusion of the simulation session, learners will be able to: 1) Identify the different etiologies of botulism, including wound, food-borne, infant, iatrogenic, and inhalational sources, 2) describe the pathophysiology of botulism toxicity and how it prevents presynaptic acetylcholine release at the neuromuscular junction, 3) develop a differential for bilateral descending muscle weakness, 4) compare and contrast presentations of myasthenia gravis, botulism, and the Miller-Fisher variant of Guillain-Barré syndrome, 5) describe measurement of neurologic respiratory parameter testing, such as negative inspiratory force, 6) outline treatment principles of wound-associated botulism, including antitoxin administration, wound debridement, tetanus vaccination, and evaluation for the need of antibiotics, and 7) identify appropriate disposition of the patient to the medical intensive care unit (ICU).

Educational methods: This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of botulism secondary to injection drug use. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board case.

Research methods: Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario.

Results: Sixteen learners completed a feedback form. This session received all six and seven scores (consistently effective/very good and extremely effective/outstanding, respectively) other than three isolated five scores. The form also includes an area for general feedback about the case at the end. Illustrative examples of feedbac

Audience: This procedure training model is designed for all levels of emergency medicine residents.

Background: Pericardiocentesis is a relatively uncommon but potentially life-saving procedure within the scope of Emergency Medicine practice. As such, the Accreditation Council for Graduate Medical Education (ACGME) designates its competency as a requirement within emergency medicine residency programs. Because of its relative rarity, simulation-based training is often utilized to fill the gaps in clinical experience during emergency medicine residency training. There have been several models of pericardiocentesis training, including gel-based models that can be purchased or constructed,1-3 non-gel models,4 and cadaveric models.5 In this paper, we describe the fabrication of a high-fidelity cadaveric model and report emergency medicine resident experience with this model. Training programs can use this model to increase trainee competence and confidence with this high-acuity, low-frequency procedure.

Educational objectives: By the end of this session, residents will gain increased procedural competence and confidence with pericardiocentesis. Residents will be able to identify necessary supplies for the procedure, identify relevant surface anatomy and ultrasound views, and successfully aspirate fluid from model effusion.

Educational methods: We created a pericardial effusion in a soft prep cadaver by placing a catheter into the pericardial sac and then infusing normal saline via intravenous fluid tubing. Learners were then able to practice aspiration of pericardial fluid via landmark and ultrasound-guided approaches under observation by facilitators able to offer real-time feedback.

Research methods: Learners were asked to complete a survey assessing pre-intervention and post-intervention subjective confidence in their ability to perform pericardiocentesis and were asked for qualitative feedback on the experience of using the training model.

Results: All residents were able to successfully visualize the pericardial effusion and perform needle aspiration via parasternal and subxiphoid approaches under dynamic ultrasound guidance, allowing needle visualization. All residents reported a subjective increase in procedural confidence and competence after practicing with this training model.

Discussion: Overall, the primary benefit of this training model cited by emergency medicine residents was that it closely approximates reality. This model is re-usable, relatively durable, and reproducible. Emergency medicine residencies associated with academic medical centers that already utilize cadavers for education may relatively easily incorporate this training model into their procedure training curriculum.

Topics: Pericardiocentesis, simulation, task trainer.

A 36-year-old immunocompetent female presented to the emergency department (ED) with five days of headache and left-sided facial pain. Physical exam showed conjunctival injection of the left eye with multiple vesicular lesions distributed along the V1 dermatome. Labs were remarkable for mild elevation in erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) with no elevation in white blood cell (WBC) count. Computed tomography (CT) with contrast of the neck revealed soft tissue stranding around the parotid gland. The patient was diagnosed with herpes zoster ophthalmicus (HZO) with concurrent ipsilateral parotitis and subsequently treated with valacyclovir, ofloxacin eye drops, topical erythromycin ointment and amoxicillin/clavulanic acid. Upon follow-up ten days after discharge, the patient noted marked improvement in her symptoms and reduction in pain. To our knowledge, this is the first case described in medical literature of a female patient with HZO and ipsilateral parotitis.

Topics: Herpes zoster opthalmicus, varicella-zoster virus, parotitis.