Simulated Mass Casualty Incident Triage Exercise for Training Medical Personnel.

Audience: The target audience is any medical professional who requires training in mass casualty incident (MCI) triage. This could apply to pre-hospital specialists, nurses, medical students, residents, and physicians. Introduction: Emergency medicine specialists must be able to triage patients quickly, especially in an MCI scenario. The simple triage and rapid treatment (START) system allows providers to categorize patients according to the urgency with which patients must access limited resources. Providers should be comfortable utilizing the START triage system before an MCI or disaster so that they can be prepared to implement it if necessary. This exercise uses simulation and gamification as instructional strategies to encourage knowledge of and comfort with the START triage system for emergency providers. Educational Objectives: By the end of this exercise, learners should be able to (1) recite the basic START patient categories (2) discuss the physical exam signs associated with each START category, (3) assign roles to medical providers in a mass casualty scenario, (4) accurately categorize patients into triage categories: green, yellow, red, and black, and (5) manage limited resources when demand exceeds availability. Educational Methods: Gamification is the use of elements of game design in non-game contexts.1 Gamification was implemented in this scenario by assigning participants to roles and teams, while creating an engaging, fun, and competitive environment. The exercise also uses low fidelity simulation (without simulation equipment) to encourage learners to practice using the START triage system in a low stakes environment.2 It is possible for the learners to be divided into two groups that each have the same patients, resources, and objectives. The team that finishes triaging all patients first would be declared the winner. However, in our implementation, we completed the exercise as a single group of learners and patients. Research Methods: Learners were given a survey at the end of implementation and also given the opportunity to discuss feedback with the instructors in a group discussion after completing the exercise. There was no formal assessment completed after the exercise. Results: Informal feedback was collected at the end of the exercise. Residents and medical students all enjoyed the experience. The feedback was overwhelmingly positive. All participants providing feedback stated they would enjoy participating in the exercise again and suggested that it is implemented annually for review of triage topics. We also received informal feedback for suggested changes which we will discuss in this article. An optional, anonymous survey was given to participants at the end of the exercise. There were six responses. Of those surveyed, 100% of participants stated the effectiveness and value of the exercise was outstanding (a rating of five on a scale of one to five). Regarding the quality of the exercise, and whether the participants felt engaged, 100% of responses gave a rating of five. When asked to consider the relevance of the session, 100% of participants selected a score of five ("I loved this session"). Regarding whether the content was applicable to practice of emergency medicine, 80% of respondents stated the session was highly relevant and 20% of responses selected a score of mostly relevant. One question asked for points of improvement for the session to which there were no responses. Discussion: Learners were assigned roles in the exercise by the incident commander, fulfilling objective three. The START categories were discussed at the beginning of the exercise by the lead proctor (using PowerPoint) and then utilized throughout the exercise, thus accomplishing objectives one and two. The residents/students filling the triage roles were primarily responsible for fulfilling objective four; however, all participants assisted in categorization of patients throughout the exercise. Finally, objective five was addressed through the various social situations and complications that can be implemented during the exercise. We chose not to implement the additional "radiation contamination" scenario (details available in the article text) due to time constraints; however, this is an additional option to address objective five. The implementation was effective based on informal feedback from participants and proctors as well as evidenced by the responses to the anonymous survey. Learners found the aspects of resource management, review of START triage, repetition of the START triage system, and medical management of various types of trauma informative and meaningful. We received valuable feedback from both learners and proctors, which we will discuss in this article. Topics: Mass casualty incident, disaster, START, gamification, simulation, emergency medicine, triage, triage category, contamination, teamwork, trauma, projectile trauma, penetrating injury, blunt trauma, intracranial hemorrhage, fracture, trauma in pregnancy, active shooter, radiation, radio communication.

Family Game Show-style Didactic for Teaching Nervous System Disorders during Emergency Medicine Training.

Audience: Emergency medicine residents and medical students. Introduction: The field of emergency medicine requires learners to build a vast library of illness scripts to be accessible in a rapid manner. Illness scripts are refined and reinforced as senior physicians teach learners common associations between diagnoses, presentation, workup findings, and treatment modalities.1 In order to examine these associations, we developed a didactic session based on the popular television game show "Family Feud" to teach important neurologic conditions related to emergency medicine. This lecture was designed to be an interactive competition, leveraging group participation, competition, and expert opinion.Neurologic emergencies are very common, affecting millions of Americans yearly. It is important for emergency medicine physicians to quickly recognize these conditions and initiate treatment because delay can lead to devastating outcomes.2 The neurologic conditions covered in the lecture were chosen based on the 2016 EM model of clinical practice, sections 7.0: Head, ear, eye, nose, throat disorders, 10.0: Systemic infectious disorders, 12.0: Nervous system disorders, and 19.0: Procedures and skills integral to the practice of emergency medicine, as well as author experience. Educational Objectives: By the end of this didactic exercise the learner will: 1) name 13 important neurologic conditions related to emergency medicine: TPA (tissue plasminogen activator) contraindications/TPA eligibility, optic neuritis, botulism, giant cell (temporal) arteritis, viral encephalitis, neurocysticercosis, rabies, myasthenia gravis, neurosyphilis, status epilepticus, Bell's palsy, dementia vs. delirium, acute inflammatory demyelinating polyneuropathy (Guillain-Barré); 2) recognize five pattern words associated with each neurologic condition; 3) understand exam findings, diagnostic tests, and/or treatments for 13 important neurologic conditions. Educational Methods: A survey was sent through a national emergency medicine education listserv (Council of Residency Directors in Emergency Medicine [CORD-EM]) asking educators to list common word or phrase associations that come to mind with a list of neurological diagnoses. A PowerPoint lecture was created in the form of the game, Family Feud, using the data from this national survey. The game Family Feud requires participant teams to guess answers to certain questions by attempting to guess the most popular answers of survey respondents. At our weekly residency conference, residents were divided into teams and offered the opportunity to compete in a game testing knowledge of nervous system disorders. Each neurology topic was then addressed by a mini-lecture to review pertinent concepts in the disease process. There was no formal assessment at the end of this lecture; however, learners actively participated throughout the lecture. Questions were discussed at the end of each round giving learners the opportunity to fully understand topics. Research Methods: Efficacy of the educational content was assessed based on learner feedback as well as observation of the learners during the exercise. Results: Learners were engaged with the exercise and verbal feedback was uniformly positive. Learners were enthusiastic about the format and requested more sessions created in a similar game. Discussion: Based on feedback as well as observation of the learners, the lecture was both an effective highyield neurology refresher and team-building exercise. Learners enjoyed the opportunity to compete as a team. Gamification seemed to improve student enjoyment, engagement, and attention, which has also been shown in the literature.3 Our residency program intends to implement similar lectures in the future. Topics: Neurology, TPA contraindications, TPA eligibility, upper motor neuron lesion, lower motor neuron lesion, optic neuritis, aphasia, botulism, ACA (anterior cerebral artery) stroke, giant cell (temporal) arteritis, Bell's palsy, viral encephalitis, Todd's paralysis, neurocysticercosis, tonic-clonic seizure, rabies, epidural hematoma, myasthenia gravis, spinal cord injury, neurosyphilis, Glasgow Coma Score (GCS), status epilepticus, Horner's syndrome, subarachnoid hemorrhage, dementia, delirium, Parkinson's disease, acute inflammatory demyelinating polyneuropathy (Guillain-Barré).

Build Your Own Eye: A Method for Teaching Ocular Anatomy and Pathophysiology.

Audience: Residents and medical students. Introduction: The eye is a critical, but often neglected, part of medical learning. This team-based learning (TBL) module was developed for emergency medicine residents and medical students; however, is applicable to any learner who should know basic eye anatomy and pathology. Emergency medicine teams, primary care providers, and ophthalmologists are most likely to encounter ocular emergencies.1-3 These emergencies are uncommon but quite dire when they occur and can result in permanent disability and life-changing morbidity.2, 4 It is critical that medical practitioners who are exposed to these types of emergencies are well prepared to evaluate and treat them.To fully understand how pathology affects the eye, it is critical that learners understand the anatomy and physiology of the eye.5, 6 Many diagnoses are associated with specific parts of ocular anatomy;5, 6 therefore, teaching pathology in an anatomy-based lesson will help learners understand the physiology. This lesson teaches learners about physiology and pathology in a systemic, anatomically oriented way. Educational Objectives: By the end of this session the participant will be able to:Describe basic anatomy of the eye.Build a basic model of the eye.Identify which diseases are associated with which parts of the eye.Identify the pathophysiology behind diseases of the eye.Name correct treatment for each disease. Educational Methods: The "build your own eye" lesson was taught as a classic team-based learning (cTBL) exercise. The modality of TBL with hands-on construction of an eye allow for social learning, competition and spatial learning related to anatomy. The creation of an eye allows residents to fully understand ocular anatomy which is not as evident when a two-dimensional paper image is used. Some learners need tactical stimuli for better understanding. This aspect of the exercise was focused on using alternative modalities to enhance spatial learning. These concepts are reinforced by the GRAT and IRAT portions of the exercise which tend to multiple choice learners. The fill-in the-blank aspect of the exercise requires recall and research to match the three-dimensional eye parts with pathology. Research Methods: Learners were given the opportunity to complete an anonymous survey. Verbal feedback was also obtained from learners during the lesson. The survey asked learners questions about the effectiveness and value of the exercise, whether the content was applicable to work in the emergency department, whether this exercise should be kept as a part of the curriculum, and whether there was any practice-changing information. Learners enjoyed the competitive aspects of the exercise and also noted that they felt much more comfortable with ocular anatomy and pathology after the lesson. Results: Learners felt that the ocular team-based learning module was effective in teaching more about the eye in an atypical way. Some learners felt that an explanation in advance of the eye building aspects of the project may have been helpful so they could have brought supplies from home. Other learners felt that they would not have brought supplies from home; thus no explanation was necessary. Discussion: Learners seemed to enjoy the experience. The competitive aspects of the TBL, where the eye models were judged for accuracy, creativity, and appearance as well as the correct answers on the worksheet, seemed to enhance learner enjoyment and engagement. Learners felt that enough time was provided for the exercise. While some learners would have preferred an explanation in advance of the project in order to bring supplies from home, others felt that this was not necessary. Educators should determine what would be preferred by their particular learning group for future implementations. Topics: Eye lid, tear duct, cornea, conjunctiva, pupil, iris, lens, anterior chamber, vitreous body, posterior chamber, retina, macula, choroid, optic disc, optic nerve, retinal artery, retinal vein, blepharitis, hordeolum, chalazion, canaliculus, dacryocystitis, corneal abrasion, corneal ulcer, ultraviolet keratitis, herpes keratitis, astigmatism, bacterial conjunctivitis, viral conjunctivitis, episcleritis, globe rupture, iritis, uveitis, anterior uveitis, posterior uveitis, hypopyon, hyphema, acute angle closure glaucoma, congenital pupillary deformity, coloboma, globe rupture, nevus, essential iris atrophy, cataracts, presbyopia, myopia, hyperopia, traumatic iritis, iridocyclitis, ciliary body melanoma, vitreous degeneration, vitreous hemorrhage, endophthalmitis, macular degeneration, retinal detachment, choroid nevus, choroid detachment, papilledema, optic nerve glioma, optic nerve meningioma, anterior ischemic optic neuropathy, retinal artery occlusion, retinal vein occlusion.

Severe Intracranial Hemorrhage at Initial Presentation of Acute Myelogenous Leukemia.

Intracranial hemorrhage (ICH) is the second leading cause of mortality among patients diagnosed with acute myelogenous leukemia (AML). The bone marrow failure associated with AML produces dysfunctional platelets, which significantly increases the risk of hemorrhagic complications within this population. In this report we discuss the case of a previously healthy female patient, newly diagnosed with AML, who rapidly developed fatal ICH.

Correlation of Simulation Examination to Written Test Scores for Advanced Cardiac Life Support Testing: Prospective Cohort Study.

INTRODUCTION: Traditional Advanced Cardiac Life Support (ACLS) courses are evaluated using written multiple-choice tests. High-fidelity simulation is a widely used adjunct to didactic content, and has been used in many specialties as a training resource as well as an evaluative tool. There are no data to our knowledge that compare simulation examination scores with written test scores for ACLS courses. OBJECTIVE: To compare and correlate a novel high-fidelity simulation-based evaluation with traditional written testing for senior medical students in an ACLS course. METHODS: We performed a prospective cohort study to determine the correlation between simulation-based evaluation and traditional written testing in a medical school simulation center. Students were tested on a standard acute coronary syndrome/ventricular fibrillation cardiac arrest scenario. Our primary outcome measure was correlation of exam results for 19 volunteer fourth-year medical students after a 32-hour ACLS-based Resuscitation Boot Camp course. Our secondary outcome was comparison of simulation-based vs. written outcome scores. RESULTS: The composite average score on the written evaluation was substantially higher (93.6%) than the simulation performance score (81.3%, absolute difference 12.3%, 95% CI [10.6-14.0%], p<0.00005). We found a statistically significant moderate correlation between simulation scenario test performance and traditional written testing (Pearson r=0.48, p=0.04), validating the new evaluation method. CONCLUSION: Simulation-based ACLS evaluation methods correlate with traditional written testing and demonstrate resuscitation knowledge and skills. Simulation may be a more discriminating and challenging testing method, as students scored higher on written evaluation methods compared to simulation.