SMALL groups A Story About Mesenteric Ischemia

: Audience: This interactive module is designed for implementation within an emergency medicine residency program. The target audience is first through fourth year (PGY 1 to PGY 4) residents, medical students, physician assistant fellows, physician assistant students, physician assistants and attending physicians. a high mortality Please write a narrative on a patient with the above diagnosis. Please include salient information such as risk factors, presenting signs and symptoms, diagnostic testing, treatment, and complications. Please write a narrative on a patient with the above diagnosis. Please include salient information such as risk factors, presenting signs and symptoms, diagnostic testing, treatment, and complications. Please write a narrative on a patient with the above diagnosis. Please include salient information such as risk factors, presenting signs and symptoms, diagnostic testing, treatment, and complications. Please write a narrative on a patient with the above diagnosis. Please include salient information such as risk factors, presenting signs and symptoms, diagnostic testing, treatment, and complications.


Linked objectives and methods:
Traditionally, didactics have been delivered via an hour-long lecture format. There is little data to support this as the standard form of information delivery. 4 In the lecture format, learners are in a passive state receiving information. For this session, we desired to have learners engaged in active learning and discussion. In order to achieve this, we utilized a flipped classroom with small groups format. Learners were assigned preselected readings and a list of open-ended questions to answer based on the assigned readings. On the didactic day, learners were divided into four different groups based on level of training with the goal of evenly distributed experience across each group.
Once divided into groups, each group was assigned one of the four types of mesenteric ischemia. Group members were assigned with writing a narrative about a patient presenting to the emergency department with the assigned diagnosis. The narratives were required to include salient information such as risk factors, presenting signs and symptoms, diagnostic testing, treatment, and complications. Groups were given forty-five minutes to complete the narrative portion of the didactic. The remaining time was utilized for sharing the narrative with the group and for facilitator wrap up.
When considering mesenteric ischemia, many learners immediately recall acute arterial occlusive mesenteric ischemia, since this is the most common form and carries the highest mortality. However, there are other forms of mesenteric ischemia, each with significant mortality rates. This session utilizes a social constructivist framework 5,6 to incorporate what the learner already knows, adds knowledge to his/her existing knowledge through readings and answering open questions, and then provides a social environment for collaboration and reflection in the narrative writing process.
Recommended pre-reading for facilitator: •

Objectives:
After participation in this module, learners will be able to:

Stations:
Stations were divided equally by post-graduate year into four groups. Once divided into groups, each group was assigned one of the four types of mesenteric ischemia. Group members were assigned with writing a narrative about a patient presenting to the emergency department with the assigned diagnosis. The narratives were required to include salient information such as risk factors, presenting signs and symptoms, diagnostic testing, treatment, and complications. Groups were given forty-five minutes to complete the narrative portion of the didactic.

Brief wrap-up:
Wrap-up involves facilitator highlighting answers to the predidactic questions.

Results and tips for successful implementation:
One week prior to our weekly emergency medicine conference, learners were assigned readings and questions for completion. On conference day, twenty-five learners were present and were divided into four groups of varying post-graduate year levels. Effectiveness of the module was evaluated two weeks postconference through the use of a quiz and a qualitative feedback evaluation tool that was distributed to all trainees. Answers from those who did not participate in the narrative writing exercise were used as a control group and compared with the answers provided by learners who did participate in the narrative writing exercise.
The evaluation tool addressed qualitative questions such as, "Do you feel that after this learning module, you have a better understanding of the disease processes of mesenteric ischemia?" Binary answer options of "Yes" and "No" were provided for these questions. Quiz questions were a combination of multiple-choice questions and open-ended questions similar to those of the initial pre-didactic questionnaire. Quantitatively, evaluations revealed a trend towards retention of the learning materials at the two-week mark; however, only eleven evaluation tools were returned. Qualitatively, learners felt they will provide better care as a result of the learning module. Our evaluation tool did reveal one area for improvement which is for the facilitator to stress during the wrap-up that there are no lab markers, such as lactate, that can confirm or rule out the diagnosis of mesenteric ischemia.

Pearls:
The key learning points of the case are the answers to the predidactic questions that are covered at the end of the session. A print out of the answers can be provided to the learners 7. What are clinical presenting signs and symptoms of the different types of mesenteric ischemia? a. Acute mesenteric ischemia i. Superior mesenteric artery (SMA) embolism -acute abdominal pain followed by rapid, forceful bowel evacuation. ii. Superior mesenteric artery (SMA) thrombosis -history of chronic abdominal pain for weeks or months followed by an acute event. b. Mesenteric venous thrombosis (MVT) -less acute presentation than arterial forms since the occlusion evolves over several days. c. Nonocclusive mesenteric ischemia (NOMI) -unexplained abdominal distension increasing in patients after cardiac surgery or dialysis. d. Chronic mesenteric ischemia -unexplained weight loss and repeated post prandial pain. 8. What is "intestinal angina?" a. Abdominal pain occurring after eating due to increased intestinal demand.
9. What is the differential diagnosis for ischemic bowel disease? a. Abdominal aortic aneurysm: rupture or expansion b. Perforated ulcer or viscus c. Ruptured ectopic pregnancy (woman of childbearing age) d. Incarcerated or strangulated hernia e. Septic shock