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Open Access Publications from the University of California


JETem is an online, open access, journal-repository for EM educators in all major topic areas. We focus on active learning and technology. Submissions include team-based learning (modified and classic), small group learning, simulation, podcasts, workshops, lectures, curricula, innovations and submissions to our image and video bank. For our fully searchable site, and details regarding submissions please go to


Modification of an Airway Training Mannequin to Teach Engagement of the Hyoepiglottic Ligament

Audience: This airway trainer modification is designed to instruct all levels of training in emergency medicine in order to familiarize trainees with airway anatomy and obtain superior views of the glottic inlet.

Introduction: During intubation with a standard geometry laryngoscope, such as the Macintosh blade, placement of the distal end of the blade within the vallecula and engagement of the median glossoepiglottic fold, also referred to as the midline vallecular fold (MVF), has long been championed by experts in airway management for its ability to improve glottic inlet visualization. This notion was further supported by the recent publication of a retrospective video review by Driver et al.1 Unfortunately, airway anatomy, including engagement of the MVF, does not receive the emphasis it deserves during intubation training of emergency medicine residents. Emergency physicians often have limited time to perform complete airway examinations, but a sound recognition and appreciation of the laryngeal inlet can serve as a roadmap to optimal laryngoscopy.2

Recent advancements in airway education emphasize visualization of airway anatomy with review of video laryngoscopy (VL) recordings to identify routine VL errors in vallecula manipulation, such as failure to engage the MVF. 3 Simulation can continue to play an essential role in enhancing trainees’ airway skills. Current airway trainers lack functional fidelity components, such an engageable MVF, resulting in a missed opportunity to teach airway skills and anatomy in a safe and controlled setting.4, 5 To address these concerns, we modified an existing airway task trainer with the addition of a simulated MVF to expose trainees to airway anatomy and adequate MVF engagement resulting in epiglottic elevation.

Educational Objectives: By the end of this education session, participants should be able to: 1. Identify relevant airway anatomy during intubation, including base of the tongue, epiglottis, midline vallecular fold, anterior arytenoids. 2. Appreciate the value of a stepwise anatomically guided approach to intubation. 3. Become familiar with the midline vallecular fold and underlying anatomy, including the hyoepiglottic ligament, and how proper placement of the laryngoscope can result in improved glottic visualization.

A Realistic, Low-Cost Simulated Automated Chest Compression Device

Audience: This simulated automated chest compression device was designed for use in simulation cardiacarrest cases involving emergency medicine residents, but it would be applicable to other learners such asnurses, pharmacists, and medical students.

Background: Automated chest compression devices (ACCD) are commonly utilized in cardiac arrest in theemergency department and by emergency medical services (EMS) as patients arrive in the ED.1 Prolongedsimulated cardiac arrest can be challenging to maintain proper chest compression depth and technique.2Resident learning may be enhanced during cardiac arrest in the simulation environment by implementing theuse of a simulated ACCD.

Educational Objectives: By the end of this educational session using a resuscitation trainer or high-fidelitymanikin, learners should be able to:1. Recognize appropriate application of simulated ACCD to an ongoing resuscitation case2. Demonstrate proper positioning of simulated ACCD in manikin model3. Integrate simulated ACCD to provide compressions appropriately throughout cardiac arrest scenario

Educational Methods: We developed a cost-effective simulated ACCD for use in resuscitation simulationcases. An initial pilot session identified components of fidelity that were used to model the simulated ACCDafter those utilized in clinical situations. Three simulated devices were created and then tested for efficacyduring high-fidelity simulation with 25 emergency medicine residents.

Research Methods: Visual analog scales were used to explore how the simulated ACCD affected perceivedrealism and stress level during the cardiac arrest simulation. Qualitative data were collected through open-ended learner feedback comments. The institutional review board at our institution reviewed this projectand determined that it was exempt.

Results: With inclusion of the simulated ACCD device, learners rated the simulation "more realistic" with anaverage rating of 74/100 and "less stressful" with an average rating of 69/100 on the visual analog scales.Learner comments noted that the use of the ACCD in simulation resulted in better resource availability andaccurate environmental noise.

Discussion: The simulated ACCD presented here was found to be effective, realistic, and practical for use bylearners in a resuscitation curriculum. Our results suggest that implementating a cost-effective simulatedACCD ($98 for supplies) in high-fidelity simulation cardiac arrest cases enhances the perceived realism of theenvironment and offers physician learners a low-stress opportunity to practice the clinical application ofACCD in cardiac arrest resuscitation. Additionally, the use of the simulated ACCD, specifically in a prolongedresuscitation, eliminated the need for physically demanding manual chest compressions. Anecdotally, insimulated environments we have observed poor-quality manual chest compressions due to an understandingthat the manikin is “not real,” leading to decreased psychological fidelity from the shared acceptance of thepoor-quality compressions. Thus, the presence of a simulated clinical device providing chest compressionscould have increased the feel of realism through improved psychological fidelity. Additionally, we note thatthe physical and psychological fidelity of this simulated device was sufficient for physicians to perceive clinicalimplementation, but may be suboptimal for assistive staff, who are focused on the specific functionality andmay benefit from training on the physical device in clinical use. Finally, our simulated ACCD resembles theclinical device our department uses; we advise modifications as appropriate to allow a simulated ACCDcreated for other learners to also resemble their clinically used ACCD.


Septic Abortion Complicated by Disseminated Intravascular Coagulation

Audience: This scenario was developed to educate emergency medicine residents on the diagnosis and management of two concurrent conditions: septic abortion and disseminated intravascular coagulation (DIC).


Introduction: Patients with an abortion (spontaneous or induced) of less than twenty weeks gestation may present with concurrent uterine infection, also known as septic abortion. One of the complications of septic abortion is DIC. Early management of both underlying etiology (septic abortion) and subsequent complications (DIC) is crucial to minimize morbidity and mortality.


Educational Objectives: At the conclusion of the simulation session, learners will be able to:

1) Obtain a relevant focused history including pregnancy history, medication use, and past medical history. 2) Develop a differential for fever and vaginal bleeding in a pregnant patient. 3) Discuss management of septic abortion, including empiric broad-spectrum antibiotics and obstetric consultation for source control with dilation and curettage (D&C).  4) Discuss expected laboratory findings of disseminated intravascular coagulation (DIC). 5) Discuss management of DIC, including identification of underlying etiology and supportive resuscitation with blood products. 6) Review the components of blood products. 7) Identify appropriate disposition of the patient to the intensive care unit (ICU).


Educational Methods: This session was conducted using high-fidelity simulation followed by a debriefing session and discussion about the diagnosis, differential, and management of both septic abortion and DIC. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. In this technique, the facilitator described something they observed in the case, outlined their reasoning as a facilitator why this observation was important or why they had questions, and then asked the learners to share their frame of reference at the time. An example: “I heard the team leader state that the platelets were normal, but then another resident disagreed.  No one paused to come to a consensus. I’m wondering why this wasn’t explored further in real time. Tell me more.” This scenario may also be run as an oral boards case or adapted for other learners such as critical care fellows.

Research Methods: Our residents were provided a survey at the completion of the debriefing session so they could rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution’s simulation center’s electronic feedback form is based on the Center of Medical Simulation’s Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form,1 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7.


Results: Thirteen learners completed a feedback form out of seventeen participants.  This session received all six and seven scores (consistently effective/very good and extremely effective/outstanding, respectively) other than two isolated 4 scores.

Discussion: This is a cost-effective method for reviewing septic abortion and DIC. The case may be modified for appropriate audiences, such as simplifying the case to septic abortion without DIC. You can also consider not showing an initial temperature with the initial set of vitals unless it is specifically asked for by the participants. We encourage readers to utilize bleeding moulage techniques as a visual stimulus to increase psychological buy-in.

Topics: Medical simulation, septic abortion, pregnancy complications, hematology emergencies, obstetric emergencies, disseminated intravascular coagulation, emergency medicine.


Electrical Storm/Refractory Ventricular Tachycardia

Audience: This simulation case was created for emergency medicine (EM) residents at all levels of training.

Background: Cardiac electrical storm (ES) is commonly defined as three or more episodes of sustainedventricular tachycardia, ventricular fibrillation, or three shocks from an implantable defibrillator within a 24hour period.1 This can occur in up to 30-40% of patients with implantable defibrillators; however, it may alsopresent in a wide variety of patients, including those with structural heart disease, myocardial infarction,electrolyte disturbances, and channelopathies.2,3 With each subsequent episode of ventricular arrhythmia,the arrhythmogenic potential of the heart may increase secondary to increased intracellular calciumdysregulation, myocardial injury, and increased endogenous release of catecholamines. The increased painand catecholamine release from cardioversion/defibrillation and exogenous epinephrine during cardiacarrest further exacerbates ES.2 This carries a significant mortality risk of up to 12% in the first 48 hours.3This case involves a basic knowledge of the Advanced Cardiac Life Support (ACLS) for ventricular tachycardia,both with and without a pulse, and the application of Sgarbossa criteria in a patient with an ST elevationmyocardial infarction (STEMI) which makes it ideal for the PGY-1. However, the case quickly becomesrefractory to the basic management prescribed in ACLS, requiring trouble shooting and quick thinking aboutdeeper pathophysiology, a skill that is crucial for all emergency medicine physicians. There are multiple waysto troubleshoot this case, making for a good variety of discussion and recent literature review on thecomplexities of a relatively common arrhythmia, ventricular tachycardia.

Educational Objectives: By the end of this simulation, learners should be able to: 1) recognize unstableventricular tachycardia and initiate ACLS protocol, 2) practice dynamic decision making by switching betweenvarious ACLS algorithms, 3) create a thoughtful approach for further management of refractory ventriculartachycardia, 4) interpret electrocardiogram (ECG) with ST-segment elevation (STE) and left bundle branchblock (LBBB), 5) appropriately disposition the patient and provide care after return of spontaneous circulation(ROSC), 6) navigate a difficult conversation with the patient’s husband when she reveals that the patient’swishes were to not be resuscitated.

Educational Methods: This simulation was performed using high-fidelity simulation followed by animmediate debriefing with nine learners who directly participated in the SIM and twenty-three residents,who were online observers via Zoom. This case was done during our conference day, and there were a totalof approximately forty total learners comprised of medical students, PGY-1, PGY-2 and PGY-3 residents. Therewere several medical students who also observed via Zoom but were not surveyed, and the survey was sentto 32 learners. The case was run three separate times with each session consisting of three-four learners atthe same level of training, with other learners in the same level of training observing via Zoomä videoplatform. Since we can only have a team of three-four learners participate per group during simulation, therest of the learners were observing the case and the debrief. There was one simulation instructor and one technician.

Research Methods: We sent an online survey to all the participants and the observers after the debrief The survey collected responses to the following statements: (1) the case was believable,(2) the case had right amount of complexity, (3) the case helped in improving medical knowledge and patientcare, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session aftersimulation helped improve my knowledge. Likert scale was used to collect the responses.

Results: A total of thirteen participants responded to the survey. One hundred percent of them eitherstrongly agreed or agreed that the case was believable and that it helped in improving medical knowledgeand patient care. Fifty-four percent strongly agreed, 38 percent agreed, and eight percent were neutral aboutthe case having the right amount of complexity. Thirty one percent strongly agreed, 61 percent agreed, andeight percent were neutral about the case giving them real-life experience. All of them agreed that thedebriefing session helped them improve their knowledge.

Discussion: The high-fidelity simulation case was helpful with educating learners with ventricular tachycardiaand fibrillation. Learners learned how to switch between various ACLS algorithms and how to manage apatient with refractory ventricular fibrillation. Learners enforced their knowledge in how to communicatewith patient’s family members when the patient does not want resuscitation.

Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management

Audience: The targeted audience for this simulation is Emergency Medicine (EM) residents. Medicalstudents, advanced practice providers, and staff physicians could all also find educational merit in thisscenario.

Background: Cardiovascular disease is the leading cause of death in the United States according to the CDC.1Coronary artery disease caused 375,000 deaths 2021 alone, and about 5% of all adult patients have a priorhistory of coronary artery disease.2 Furthermore, chest pain itself is a common chief complaint encounteredin the ED, with nearly 8 million visits annually occurring throughout the United States, with 10-20% of thosepatients ultimately being diagnosed with an acute coronary syndrome3, including ST-elevation myocardialinfarction (STEMI). Given this, it is essential that EM residents are well prepared to care for all patientspresenting with chest pain, regardless of the acute care or emergency setting.Throughout their training, most EM residents typically learn and evaluate patients at a large tertiary orquaternary medical center with 24-hour catheterization laboratory availability. For patients presenting withelectrocardiogram (EKG) findings consistent with STEMI, the standard of care is for the patient to undergocardiac catheterization and stent placement within 90 minutes of arrival. Unfortunately, only half of patientsliving in rural areas have a cardiac catheterization-capable facility available to them within a 60-minutedriving radius, making it difficult for those patients to undergo cardiac catheterization within the desired timeframe.4 These patients remain candidates for thrombolytic therapy, but given infrequent opportunities tolearn about and deploy thrombolytic agents during residency training, graduating EM residents may beunfamiliar with indications, dosing, and contraindications before they begin practice. Furthermore, the recent EM workforce data suggests that although there may be an oversupply of 8,000 emergency physiciansby 2030, robust practice opportunities for emergency physicians remain in rural settings.5 Althoughhistorically EM graduates have not selected rural areas for practice, with only approximately 8% ofemergency physicians practicing in rural areas,6 it is likely that given the opportunities present and perceivedsaturation in many non-rural settings, more EM graduates will pursue practice in a rural setting. With thesechanging practice dynamics in mind, this simulation provides the opportunity for residents and medicalstudents to experience the management of a STEMI in the rural setting, with a focus upon the indications,contraindications, dosing, and disposition of a patient receiving thrombolytics.Educational Objectives: By the end of this simulation, learners will be able to:

1. Diagnose ST elevation myocardial infarction accurately and initiate thrombolysis in the rural settingwithout timely access to cardiac catheterization.2. Engage the simulated patient in a shared decision-making conversation, clearly outlying the benefitsand risks of thrombolysis.3. Identify the indications and contraindications for thrombolysis in ST elevation myocardial infarction.4. Arrange for transfer to a tertiary care center following completion of thrombolysis.

Educational Methods: This scenario is a simulated encounter in a rural emergency department settingrequiring the diagnosis of a STEMI, a discussion with the patient regarding the risks and benefits ofthrombolysis prior to administration, administration of thrombolysis, and transfer of patient to a higher levelof care.

Research Methods: The educational content of this simulation as a teaching instrument was evaluated bythe learner utilizing an internally developed survey after case completion. This survey was reviewed forprecision of language and assessment of learning objectives by our simulation faculty and other members ofour West Virginia University Emergency Medicine Department of Medical Education. The learner was askedto specify any prior experience with rural STEMI management as well as quantify via a five-point Likert Scale,where 1 = very uncomfortable and 5 = very comfortable, their level of comfort with thrombolysis before andafter the scenario as well as their comfort with having a shared decision-making conversation with patientswith regards to thrombolysis. Learners were also asked to rank the helpfulness of this simulation in preparingthem for administering thrombolytics for STEMI in a rural setting on a five-point Likert scale, where 1 = nothelpful and 5 =very helpful. An open response section was also provided to allow learners the opportunity tocomment directly on any aspect of the simulation.

Results: Data was collected anonymously from 16 PGY1-3 resident learners via surveys with a 100% responserate. Overall, the feedback received regarding the simulation was positive. There was a low average comfortlevel with administering thrombolytics and having a shared decision-making conversation regardingadministering thrombolytics. There was a high average rating of the helpfulness of this simulation in preparing residents for this conversation as well as managing STEMIs in a rural setting. Subjective commentsregarding the simulation were universally positive.

Discussion: The management of STEMI in the rural emergency department differs significantly from theenvironment in which many EM residents train. As a leading cause of death in the United States, STEMImanagement is a vital component of EM resident education. Although the concept of thrombolysis in the rural setting is discussed, the opportunity for real-world experience in its execution is often limited despitemany graduates ultimately working in rural emergency departments. This simulation sought to provide arealistic patient encounter to promote familiarity and comfort in the identification, patient discussion andexecution of thrombolysis in the treatment of a STEMI. The educational content was shown to be effectivevia learner survey completion.

Team-Based Learning

Hypertensive Emergency Team-Based Learning

Audience: The target audiences for this team-based learning (TBL) activity are resident physicians andmedical students.

Introduction: According to the Centers for Disease Control and Prevention (CDC), nearly half of the adults inthe United States have hypertension,1 which is a leading cause of cardiovascular disease and prematuredeath.2 In extreme cases, patients may present in hypertensive emergencies, defined as an acute, markedelevation of systolic blood pressure >180mmHg or diastolic blood pressure >120mmHg with evidence oforgan dysfunction.3,4 Patients presenting to the emergency department (ED) with symptoms of hypertensiveemergencies must be promptly diagnosed and treated to prevent further morbidity and mortality. This TBLutilizes four clinical cases to educate resident physicians and medical students not only on the recognition ofhypertensive emergencies, but also on the workup, management, and disposition of patients who present tothe ED with hypertension.udience: The target audiences for this team-based learning (TBL) activity are resident physicians andmedical students.

Educational Objectives:By the end of this TBL session, learners should be able to: 1) define features ofasymptomatic hypertension versus hypertensive emergency, 2) discuss which patients with elevated bloodpressure may require further diagnostic workup and intervention, 3) identify a differential diagnosis forpatients presenting with elevated blood pressures, 4) recognize the features of different types of end-organdamage, 5) review an algorithm for the pharmacologic management of hypertensive emergencies, 6) indicatedosing and routes of various anti-hypertensive medications, 7) choose the appropriate treatment for apatient who is hypertensive and presenting with flash pulmonary edema, 8) identify an aortic dissection oncomputed tomography (CT), 9) choose the appropriate treatment for a patient who is hypertensive andpresenting with an aortic dissection, 10) identify intracranial hemorrhage on CT, 11) choose the appropriatetreatment for a patient who is hypertensive and presenting with an intracranial hemorrhage, and 12)describe the intervention for warfarin reversal.

Educational Methods: This is a classic TBL that includes an individual readiness assessment test (iRAT), amultiple-choice group readiness assessment test (gRAT), and a group application exercise (GAE).

Research Methods: Learners and instructors were given the opportunity to provide verbal feedback aftercompletion of the TBL. Learners included senior medical students and first-, second-, and third-yearemergency-medicine residents. Learners were specifically asked if they felt the cases were educational,relevant, and useful to their training.

Results: Six resident physicians and three medical students volunteered their verbal feedback, and agreedwhen they were specifically asked if the cases were educational, relevant, and useful to their training. Thesame learners also agreed when asked if they felt the TBL was a more enjoyable activity than a direct lectureto refresh their knowledge and skills. One instructor observed that interns and medical students weregenerally able to reach a correct diagnosis; however, they seemed to struggle more with describingappropriate pharmacologic interventions when compared to more senior learners.

Discussion: Hypertension is a common complaint and incidental finding in patients presenting to the ED.Given its non-specific value, it can be a difficult topic for the novice healthcare provider to master. Thedifferential diagnosis for a patient presenting with hypertension is vast, ranging from benign to emergent,and can sometimes necessitate minimal to substantial workups. Thus, this TBL is a useful, relevant, andeffective exercise for residents-in-training to review and understand the management of hypertension.

Visual EM

A Case Report of Acute Compartment Syndrome

Acute compartment syndrome (ACS) is a surgical emergency which requires prompt identification andintervention to prevent irreversible tissue damage. Here we present the case of a 64-year-old male withlower extremity tenderness following a crush injury. This patient presented to the emergency department(ED) more than 12 hours after the initial incident occurred and was found to have a firm right calf withdecreased sensation and absent distal pulses on his right leg. The patient’s outer compartment pressuremeasured 32 mmHg. Because these findings were concerning for acute compartment syndrome, emergentfasciotomies of the four compartments of the lower right leg were performed with improvement inneuromuscular compromise. Early identification of the condition permitted a prompt recovery for the patientwho was discharged home on day five. This case report reviews the clinical presentation and interventionalmodalities and aims to provide new images to help visualize a diagnosis of ACS.

Vaginal Bleeding Due to Iatrogenic Uterine Perforation – A Case Report

Uterine perforation is a rare but potentially life-threatening complication of gynecologic procedures. Seriouscomplications include hemorrhage, infection, and injury to surrounding organ systems (eg, gastrointestinal,urological, vascular, etc.). Risk factors include advanced maternal age, prior gynecologic surgeries, and otheranatomical features that impact the difficulty of accessing the uterine cavity. In this case report, we discussa patient who presented to the emergency department (ED) with diffuse abdominal pain and vaginal bleedingthat occurred after an elective dilation and curettage (D&C) for a termination of pregnancy. The diagnosiswas suspected clinically and confirmed by imaging including ultrasound (US) and computed tomography (CT)of the abdomen and pelvis. The patient was managed operatively with a multidisciplinary approach includingGynecology, General Surgery, and Urology. The patient was stabilized and eventually discharged. Uterineperforation should be included in the differential for patients with a history of recent gynecologicinstrumentation presenting with abdominal pain and vaginal bleeding. The stabilization of these patientsrequires aggressive volume resuscitation, controlling the source of bleeding, and emergent surgicalconsultation.

A Case Report Evaluating Gastric Emphysema versus Emphysematous Gastritis

Gastric emphysema (GE) and emphysematous gastritis (EG) share similar clinical presentations but exhibitdrastically different prognoses. While GE is generally benign, EG is associated with mortality rates up to 60%.Here, we present the case of a 29-year-old female patient who presented to the emergency department (ED)with symptoms of nausea, vomiting, and epigastric abdominal pain. Clinical evaluation revealed tachycardia,pain out of proportion, leukocytosis, and metabolic acidosis. Computed tomography (CT) scan unveiled thepresence of air within the gastric wall, and a presumptive diagnosis of gastric emphysema was made. Thepatient responded positively to conservative management and was discharged after a two-dayhospitalization. This case report emphasizes the need for physicians to adeptly distinguish between GE andEG. Timely identification and precise differentiation of the two conditions allow for timely and tailoredmanagement, ultimately leading to improved clinical outcomes in patients. By providing insights into theetiologies, clinical presentations, and imaging findings for the two pathologies, we aim to empower cliniciansto make informed decisions for optimal patient care.

Telescoping into Adulthood: A Case Report of Intussusception in an Adult Patient

Intussusception is a familiar diagnosis among the pediatric population; however, it is rarely consideredamong the adult population due to a myriad of life-threatening pathologies within the abdomen. We presentan adult female who presented to the emergency department (ED) with abdominal pain and constipation.Laboratory testing and a computed tomography (CT) scan of the abdomen were ordered. Laboratory testresults were notable for an elevated lymphocyte count as well as leukocyte esterase, white blood cells (WBC),and bacteria seen on urinalysis. The computed tomography scan detected a colo-colic intussusceptionsecondary to a benign mass within the bowel lumen. The mass was surgically resected and the patient hadan uneventful postoperative course. This unique case represents the occurrence of a pathology to which theadult population is not immune, and therefore should not be overlooked when evaluating a non-specific caseof abdominal pain.