Learner reflections on a postgraduate emergency medicine simulation curriculum: a qualitative exploration based on focus group interviews.

OBJECTIVES: To describe postgraduate emergency medicine (EM) residents' perceptions of simulation-based curriculum immediately post-simulation training. METHODS: This interpretive qualitative study explores residents' reflections on a city-wide, adult EM simulation-based curriculum. Focus group interviews gather residents' insights immediately post-simulation. Postgraduate trainees from the University of Toronto EM residency program were eligible to participate. We explored participants' perceptions of how well learning objectives were addressed, helpful/challenging aspects of the simulations, feelings during sessions, debriefing/pre-briefing, simulation integration into the broader EM curriculum, and anticipated changes in practice after the session. RESULTS: Our findings indicate that EM residents' learning goals for the simulation sessions evolve as they progress through residency training. Junior trainees report performance-oriented goals while senior trainees report learning-oriented goals. Differing motivations may affect residents' perceptions of the quality of the simulation experience. Junior residents want to feel prepared for the scenario and primed with the appropriate knowledge to manage the case. Senior residents focus on developing teamwork competencies and on mastering new clinical skills in the simulation environment. CONCLUSIONS: Junior and senior emergency medicine residents differ in their goal orientation during simulation-based training. Educators who develop simulation-based curricula should be mindful that junior residents may benefit from preparatory materials while senior residents prefer to be challenged. Resident reflections may significantly contribute to improvement of simulation-based curricula.

RéSUMé: OBJECTIF: Décrire la perception du programme de formation par simulation des résidents en médecine d'urgence (MU) immédiatement après un entraînement par simulation. MéTHODES: Cette étude qualitative interprétative explore les réflexions des résidents au sujet d'un programme axé sur la simulation en MU pour adultes à travers la ville. Les entretiens des groupes de discussion recueillent les aperçus des résidents immédiatement après la simulation. Les stagiaires de troisième cycle du programme de résidence en MU de l'Université de Toronto étaient admissibles à participer. Nous avons examiné les perceptions des participants sur la manière dont les objectifs d'apprentissage étaient abordés, les aspects utiles / exigeants des simulations, les sentiments pendant les sessions, le débriefing / pré-briefing, l'intégration de la simulation dans le programme plus large de la MU et les changements anticipés dans la pratique après la session. RéSULTATS: Nos résultats indiquent que les objectifs d'apprentissage des résidents en MU pour les séances de simulation évoluent au fur et à mesure qu'ils progressent dans la formation en résidence. Les stagiaires juniors rapportent des objectifs axés sur la performance tandis que les stagiaires avec plus d'ancienneté rapportent des objectifs axés sur l'apprentissage. Des motivations différentes peuvent affecter la perception qu'ont les résidents de la qualité de l'expérience de simulation. Les résidents assistants veulent se sentir préparés pour le scénario et équipés des connaissances appropriées pour gérer le cas. Les résidents avec plus d'ancienneté se concentrent sur le développement des compétences de travail d'équipe et sur la maîtrise de nouvelles compétences cliniques dans l'environnement de simulation. CONCLUSIONS: Les résidents assistants et ceux avec plus d'ancienneté en médecine d'urgence diffèrent dans leur orientation vers les objectifs au cours de la formation par simulation. Les éducateurs qui développent des programmes axés sur la simulation doivent être conscients que les résidents assistants peuvent bénéficier des matériels préparatoires tandis que les résidents avec plus d'ancienneté préfèrent être mis au défi. Les réflexions des résidents peuvent contribuer de manière significative à l'amélioration des programmes axés sur la simulation.

Case Report of Methemoglobinemia: An Illustration That It Is Time to Report all Results with Arterial and Venous Blood Gas Result Reporting.

BACKGROUND: Methemoglobinemia and carbon monoxide poisoning are potentially life-threatening conditions that can present with nonspecific clinical features. This lack of specificity increases the probability of misdiagnosis or avoidable delays in diagnosis and management. These conditions are both treatable with antidotes of methylene blue and oxygen, respectively. Modern blood gas analyzers have the ability to measure carboxyhemoglobin (COHb) and methemoglobin (MetHb) levels without any additional resources. However, these results, although readily available from the machine used to perform the analysis, are not fully reported by some hospital clinical laboratories. CASE REPORT: A 49-year-old male presented with shortness of breath and cyanosis after inhaling cocaine via a nasal route ("snorting"). Methemoglobinemia was not initially considered in the differential diagnosis. However, the diagnosis of methemoglobinemia was made once newly routinely reported laboratory results revealed an elevated MetHb level. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Routinely reporting MetHb and COHb levels with arterial and venous blood gas results will facilitate making the diagnoses of these infrequently diagnosed causes of hypoxia more quickly so that early treatment of these uncommon but potentially lethal conditions can be initiated promptly.

A new way to look at simulation-based assessment: the relationship between gaze-tracking and exam performance.

OBJECTIVE: A key task of the team leader in a medical emergency is effective information gathering. Studying information gathering patterns is readily accomplished with the use of gaze-tracking glasses. This technology was used to generate hypotheses about the relationship between performance scores and expert-hypothesized visual areas of interest in residents across scenarios in simulated medical resuscitation examinations. METHODS: Emergency medicine residents wore gaze-tracking glasses during two simulation-based examinations (n=29 and 13 respectively). Blinded experts assessed video-recorded performances using a simulation performance assessment tool that has validity evidence in this context. The relationships between gaze patterns and performance scores were analyzed and potential hypotheses generated. Four scenarios were assessed in this study: diabetic ketoacidosis, bradycardia secondary to beta-blocker overdose, ruptured abdominal aortic aneurysm and metabolic acidosis caused by antifreeze ingestion. RESULTS: Specific gaze patterns were correlated with objective performance. High performers were more likely to fixate on task-relevant stimuli and appropriately ignore task-irrelevant stimuli compared with lower performers. For example, shorter latency to fixation on the vital signs in a case of diabetic ketoacidosis was positively correlated with performance (r=0.70, p<0.05). Conversely, total time spent fixating on lab values in a case of ruptured abdominal aortic aneurysm was negatively correlated with performance (r= −0.50, p<0.05). CONCLUSIONS: There are differences between the visual patterns of high and low-performing residents. These findings may allow for better characterization of expertise development in resuscitation medicine and provide a framework for future study of visual behaviours in resuscitation cases.