Journal of Education and Teaching in Emergency Medicine

Audience: This simulation was designed primarily for emergency medicine residents and pediatric emergency medicine residents. Additionally, off-service residents, neurosurgical residents, pediatric residents, faculty, and medical students may benefit.

Introduction: Ventriculoperitoneal (VP) shunts are the treatment of choice for patients suffering from hydrocephalus.Hydrocephalus affects about 125,000 patients in the United States, and 33,000 VP shunts are implanted in patients every year.¹ However, these devices can malfunction and can cause complications. It is important for the emergency department physician to recognize when these devices are not functioning correctly to prevent life-threatening complications. Training for VP shunt malfunction can be variable depending upon the patient population seen by residents. Therefore, we outline a simulation for mechanical VP shunt malfunction to provide learners with exposure to this topic.

Educational Objectives: The objective of this simulated case is to increase learner knowledge and develop the skills necessary to troubleshoot VP shunt malfunction. By the end of this simulation, learners should be able to: 1) review pertinent historical and physical exam points for a shunt patient, 2) recognize the signs and symptoms of VP shunt malfunction, 3) review an algorithm for diagnosing VP shunt malfunction, 4) discuss treatment for common complications of VP shunt dysfunction, and 5) recall the indications for an emergent VP shunt tap.

Educational Methods: In this study, a high-fidelity mannikin with a do-it-yourself (DIY) task trainer was used in a simulated case scenario. Learners were required to recognize the signs and symptoms of shunt dysfunction, administer the appropriate treatment, and appropriately disposition the simulated patient.

Research methods: Residents completed pre- and post- simulation surveys to assess their perceived knowledge and confidence regarding the diagnosis and management of VP shunt malfunction. To prevent priming or diagnostic cueing, the term “neurologic device” was used in the pre-simulation surveys. This wording may significantly limit direct comparison between pre- and post-simulation responses.  Learners were also asked to provide feedback on the utility of the simulation for their future practice and usefulness of the topic. 

Results: Learners reported high levels of confidence in recognizing signs and symptoms of shunt dysfunction and managing complications after the simulation. Residents also reported that the case was valuable for their future clinical practice and felt as though the simulation experience was positive.

Discussion: Overall, the educational content was effective. The simulation appears to be useful in addressing knowledge gaps in managing VP shunt dysfunction and may increase learner confidence. 

Topics: Medical simulation, ventriculoperitoneal shunt dysfunction, hydrocephalus, pediatrics, increased intracranial pressure, shunt tap, neurologic emergencies.

Audience: This clinical decision-making (CDM) case is intended for emergency medicine (EM) residents of all levels.

Introduction: About 700,000 patients every year in the United States experience an acute ischemic stroke.¹ Morbidity and mortality from an ischemic stroke may be limited from timely diagnosis and acute management, including specialist involvement, appropriate blood pressure control, and evaluation for possible thrombolytic therapy. EM residents should be familiar with stroke management principles whether they work in an academic, community, or rural setting.

Educational Objectives: By the end of this clinical decision-making case, learners will be able to: 1) demonstrate familiarity with the CDM case format and case play, 2) describe important historical information to obtain when suspecting an acute stroke, 3) outline key diagnostic tests to rule out other causes of acute neurologic deficits, 4) outline acute management strategies for acute ischemic stroke, 5) propose an appropriate disposition plan for patients with an acute ischemic stroke.

Educational Methods: This is a clinical decision-making boards case as outlined by the American Board of Emergency Medicine (ABEM). Each learner was paired with one instructor for the case, a scoring checklist by the instructor was used, structured debriefing time was incorporated into the assessment, and learners were given the opportunity to provide qualitative feedback after the case.

Research Methods: Each CDM case session lasted approximately 25 minutes, with 15 minutes for the case and 10 minutes for debriefing and feedback. A 26-point critical action checklist was developed to evaluate each learner’s performance, with each point reflecting an equally weighted item. Learners then provided verbal feedback on the cases to the examiners at the conclusion of their assessments. 

Results: Thirty-nine categorical emergency medicine residents participated as learners for this clinical decision-making session, including 10 third-year residents, 12 second-year residents and 17 first-year residents. The average overall score was 17.3 of 26 possible points.  Performance with respect to post-graduate year (PGY) is as follows: 17.7 for PGY-3s, 18.8 for PGY-2s, and 15.9 for PGY-1s.  One resident had a perfect score. 

Discussion:  Performance of our learners varied and unexpectedly, our second-year residents outperformed our third-year residents. This is likely due to our PGY-2 learners being responsible for the primary care of stroke patients in our department, which makes their identification and management of acute ischemic stroke patients likely more recently retrievable.

ABSTRACT:

Audience and type of curriculum: This curriculum is designed to prime pre-medical-field undergraduate students with medical research concepts and skills necessary to assist Emergency Medicine (EM) residents on clinical research projects in a community hospital setting.

Length of curriculum: The PRIMER lecture series should run two to three days with six hours of lecture content to be covered. Project completion and poster presentation should take 8-16 weeks depending on time constraints, resources, and project scope.

Introduction: Scholarly research has taken an increasingly prominent role in both undergraduate and graduate medical education. However, researchers and clinician-teachers can be limited in productivity due to lack of funding, time, and formalized infrastructure. This can result in siloed activities, incomplete or unrealized ideas, and often make research challenging for student and resident physicians alike.¹ These barriers to participating in scholarly research are further exacerbated for those in community-hospital-based residencies and community- or rural-medicine educational tracks because these facilities have further reduced access to research personnel and resources.^{2, 3}Simultaneously, research literacy and experience are becoming increasingly critical qualifications for admission to professional medical educational programs.^4,5 Developing structured research training and mentorship for premedical students in community hospital settings can simultaneously enhance residents' research capacity and provide premedical students with critical experience and exposure needed for medical school admission.

Educational Goals: The purpose of this project is to design a didactic training to provide undergraduate research assistants the necessary training to enhance resident research projects in the emergency department.

Educational Methods: The educational strategies used in this curriculum include: 1) Blended learning of in-person lectures and online readings and resources implemented in a three-day workshop to provide foundational research knowledge, skills, and resources to research assistants before beginning projects, 2) Experiential learning implemented in workshops interspersed through the three-day intensive, allowing students to begin literature searches, compose IRB proposals, and develop data management and analysis plans that apply to their assigned research project, and 3) Group Learning where students develop action plans, communication, and presentation skills.

Research Methods: The educational outcomes were quantitatively and qualitatively analyzed by administration of a pre- and post-test and self-evaluation using a 5-item Likert scale as well as the completion of project and presentation of poster. Average examination scores and self-evaluation scores were analyzed for trends. Learner feedback was collected concurrently with the final assessment.

Results: Average pre-test and self-evaluations scores were 3.29 ± 1.11 out of 7 and 11.0 ± 1.63 out of 20, respectively. Average post-test and self-evaluation scores increased dramatically to 5.71 ± 0.95 and 17.86 ± 1.77, demonstrating student acquisition of concepts and increased confidence in their knowledge of medical research. End-of-program scores were 6.43 ± 0.53 and 17 ± 1.15, respectively, and demonstrated good concept retention and retained confidence.

Discussion: The PRIMER model serves to both increase the capacity for resident-driven research in community hospital settings and provide pre-professional students with training and experience to help matriculate and succeed in medical programs. Resident physicians (PGY1-PGY4, n=15) indicated that the PRIMER program would be very helpful in designing (n=12), implementing (n=12), and completing (n=13) a research project. We were successful in implementing the program with three of four projects completed in the initial time frame planned. One project was not completed, and one contributing factor was resident vacation time. Future iterations in our program will consider the full resident schedule for the duration of the program. Research assistants feedback suggested improvements on coordinating resident schedules (vacation and graduation) with the program. We plan to implement the program two to three times each year to accommodate the overwhelming undergraduate interest and further enhance our residents' ability to ask clinically relevant research questions and explore those results in a community-based EM program.

Topics: Medical research, statistics, data analysis, mentorship, data management, research ethics.