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CHAPTER 1
Introduction: How to use this book
Traci L. Thoureen and Sara B. Scott
University of Maryland School of Medicine, Baltimore, MD
Simulation has become an integral tool in medical education and the specialty of emergency medicine (EM) is no exception. Simulation curriculums have increasingly become integrated into standard EM training. In fact, as of 2008, one study reported that of 134 EM residencies surveyed in the United States, 91% used some form of simulation in their postgraduate training.1
With increasing utilization of simulation as a teaching tool, there has been more demand from educators for workshops and training that focus on how to teach using simulation. This workbook is designed with those demands in mind. It is meant to act as a “lesson plan” for physician educators to use at the “bedside” in the simulation laboratory or in any space that is used to conduct simulation.
This workbook is organized with the basic clinical competencies of EM in mind. The chapters incorporate topics listed by the American Board of Emergency Medicine as included in the certification examination. Each chapter includes 3–4 individual simulation cases that highlight subject material pertinent to the chapter topic. In many of the cases, alternative options are described for use with multiple levels of learners (students, junior or senior postgraduate learners).
Although each individual simulation case is unique, the presentation format for all of the cases is the same. The layout for each case starts with specific educational objectives for that case, together with a list of suggested critical actions. For those who are working within the United States postgraduate training system, we have notated the relevant Accreditation Council of Graduate Medical Education (ACGME) clinical competencies for each learning objective and critical action.
Immediately following the critical actions, you will find an outline for the case set-up. This includes a description of the physical environment, mannequin, props, distractors, and actors that are recommended for each simulation. To aid in the case set-up, an online resource is provided with this workbook (at www.wiley.com/go/thoureen/simulation/workbook) and includes imaging and laboratory studies pertinent to each case. The online resource is presented in a PowerPoint format and can be printed out, downloaded, or shown in real time on computer screens/monitors during the simulation session.
After the section on set-up, you will find a brief narrative of the case, which essentially contains the information found on most emergency department triage sheets. There is a description of the initial mannequin conditions and a case narrative which details the changes in conditions that will occur in the mannequin after a specific time interval or in response to a learner intervention. Accompanying flow sheets also outline the general sequence of actions for each case.
Throughout the case, you will see text boxes. These text boxes highlight specific details in the case that can be altered based on the degree of fidelity of your mannequin or on the skill level of your learner. In this way, each case can be manipulated to fit your teaching needs and available resources.
At the end of each case, you will find information to aid in debriefing. Instructor notes provide basic background information for your facilitators about the specific case topic. There is also a list of potential questions that can be used during the debriefing session with your learners. Finally, you will find a list of selected reading that can be used in preparing for the simulation and some are suitable to be distributed to learners either prior to or following the simulation.
We hope that you will find this workbook a useful tool in the development or continuation of a successful emergency medicine simulation curriculum at your institution. Keep in mind that each simulation case is dynamic and can be modified in a variety of ways to suit best the needs of your learners and/or the fidelity of your mannequin. As such, this workbook provides a basic template for the design of an emergency medicine simulation curriculum for learners at any stage in their education and for facilities with varying levels of technical capability.
Reference
1. Okuda Y, Bond W, Bonfante G, et al. National growth in simulation training within emergency medicine residency programs, 2003–2008. Acad Emerg Med 2008;15(11):1113–1116.
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CHAPTER 2
Vascular emergencies
Sarah B. Dubbs and Traci L. Thoureen
University of Maryland School of Medicine, Baltimore, MD
Pulmonary embolism
Educational goals
Learning objectives
Primary:
1. Recognize clinical signs of pulmonary embolism (PE) [Medical Knowledge].
2. Order appropriate diagnostic tests for PE [Medical Knowledge].
3. Order appropriate treatment for PE and its complications [Medical Knowledge, Patient Care].
Secondary:
1. Demonstrate professionalism and communication skills in consultation with other physicians and in working with ED nurse [Interpersonal and Communication Skills, Professionalism].
2. Direct proper disposition to/appropriate consultation with the ICU [Systems-based Practice].
Critical actions checklist
Assess airway, breathing, and circulation [
Patient Care]
Place patient on cardiac monitor and establish IV access [
Patient Care]
Order CT angiography (or locally appropriate imaging) and recognize signs of PE [
Medical Knowledge]
Initiate proper therapy: (1) heparin and/or thrombolytic for PE, (2) high-flow oxygen/non-invasive positive-pressure ventilation/intubation for hypoxia, and (3) IV vasopressor for hypotension/shock [
Medical Knowledge, Patient Care]
Call and communicate to ICU for disposition [
Interpersonal and Communication Skills, Professionalism]
Critical actions can be changed to address the educational needs of the learner. For example, a resident preparing for the oral board examination may have more specific critical actions such as ordering a pregnancy test before radiologic imaging, etc.
Simulation set-up
Environment:
Emergency Department treatment area.
Mannequin:
Simulator mannequin, on a stretcher or hospital bed. Mannequin should be female, moulaged with left leg swelling.
This moulage may be accomplished in both high and low-tech ways. You may purchase SimLeggings™ (Eriter Creations, Stirling, AB, Canada) or, for a lower tech version, nude-colored self-adherent elastic wrap can be placed overtop of memory foam (¼–½ inch) with nude pantyhose on top, or simply a label or photograph of your desired appearance can be placed on the extremity.
Props:
To be displayed on plasma screen/computer screen or printed out on handouts in scenario room when asked for/return from laboratory.
- Images (see online component for Pulmonary Embolism, Scenario 2.1.ppt, at www.wiley.com/go/thoureen/simulation/workbook)
- ECG with sinus tachycardia.
- Chest X-ray showing normal cardiac silhouette.
- CT angiography of chest showing right-sided PE.
- Venous Doppler ultrasound of left leg showing deep venous thrombosis.
- Labs (see online component as above)
- Complete blood count.
- Chemistry panel.
- Coagulation panel.
- Urinalysis.
- Urine pregnancy test.
- D-dimer.
Available in the treatment room:
- Basic airway and code cart.
- High-flow face mask.
- Medications:
- Liter bags of 0.9% normal saline (NS) and lactated Ringer’s (LR).
- Rapid sequence intubation (RSI) medications pre-labeled in syringes (paralytic and induction medication of choice for your institution).
- Heparin in pre-labeled liter bag.
- Thrombolytic typically utilized at your institution.
- Non-invasive positive pressure airway equipment (BiPAP or CPAP).
Distractor:
None.
Actors:
