Journal of Education and Teaching in Emergency Medicine

Audience: The target audience for this small group workshop are interns and residents of any specialty.

Introduction: All residents are expected to become proficient teachers in a variety of settings as they progress in training, and many residency programs offer advanced training or credentialing in medical education.1,2 Recently, some emergency medicine programs have also begun to offer a formal medical education fellowship. Traditional resident education has been in the form of didactic lectures such as morning report, noon conference, and Grand Rounds as well as small group bedside teaching by attendings. Due to the COVID-19 pandemic, in many cases these learning structures have been reengineered into a hybrid or virtual model.3 This new educational paradigm has spurred the search for best practice teaching methods across a variety of situations. 4 Active teaching, characterized by audience engagement and self-directed learning, has been shown to promote deeper understanding and improved knowledge retention when compared to standard didactic teaching.5,6

Educational curricula for residents now acknowledge the importance of audience participation, with more emphasis on the use of interactive teaching techniques. A review of residents-as-teachers curricula highlighted the importance of disseminating practical resources for how to effectively teach residents to be better educators.7 However, in the literature there are few examples of how to teach residents to implement these best practice interactive teaching methods. We designed a simple, interactive, and easily reproducible workshop for introducing the concepts of active teaching to residents that allows for active engagement with these techniques.

Educational Objectives: By the end of this small group exercise, learners will be able to: 1) assess interactive teaching techniques that support learning in various environments; 2) incorporate active teaching techniques into a variety of real-world teaching scenarios; 3) implement selected techniques to enrich one’s own teaching practice.

Educational Methods: Our workshop was designed to include elements of gamification, which facilitates teamwork and competition and can be used to engage learners in higher levels of learning.8 We began by performing a literature search for descriptions of active teaching techniques that had been used in the medical setting.9-14 We developed a list of 15 popular active teaching strategies and created a one-page menu which briefly described each strategy. Utilizing the flipped classroom model, we identified three articles (references 10, 11, and 14) which reviewed active teaching techniques and sent these articles to our participants via email one week before our session with instructions to read the articles and come prepared to discuss them at our session. We created two sets of playing cards for our activity. The first set of playing cards was titled “teaching setting” and included common venues for teaching in clinical medicine: morning report, grand rounds warm-up (which at our institution consists of a 15-minute lecture given to a large audience in a formal setting), small group, bedside teaching, journal club, and an online/virtual lecture. The second set of playing cards included simulated audiences that could be present at a teaching session: peers (residents), medical students, attendings, or mixed audience. To account for larger groups of residents, we made multiple copies of each card within the respective card set.

At the beginning of the workshop, the learning objectives were discussed and the menu with the 15 active teaching techniques was reviewed along with the assigned pre-reading articles. Residents were asked to name different active teaching techniques and give examples they experienced during their residency or medical school education. Participants (pediatric and medicine-pediatric residents) were then placed in groups of three or four, and each group drew one teaching setting card and one audience card. All groups were given the same general topic (diabetic ketoacidosis) and each group was challenged to design a short teaching activity relevant to the topic that incorporated active teaching techniques appropriate for their setting and audience. After a short period of planning, each group reported how they would teach the topic and which active teaching strategies they would use. After each group described their approach, they received peer feedback from the other groups’ participants. Key aspects of the proposed active teaching techniques and any barriers to implementation were discussed. The cards were then reshuffled for each group, and the exercise was repeated with a different general topic (in our session, we chose developmental milestones).

Research Methods: Participants provided anonymous feedback in the form of surveys which assessed the efficacy of the workshop. Participants were also asked to commit to three active teaching techniques they would incorporate into teaching sessions within the next six months.

Results: Our workshop was presented for two sequential years: 2022 and 2023. Our workshop was attended by 32 residents in year one and 36 residents in year two. All participants filled out the anonymous evaluation survey at the conclusion of the exercise. Eighty-five percent of respondents rated the session as “highly organized,” and a majority strongly agreed that the workshop was effective for learning active teaching techniques (78%) and taught them concrete techniques that they could incorporate into their future teaching (88%). Participants reported that they were most likely to utilize Jigsaw (31 respondents), Polling/audience

response (29 respondents), case-based learning (25 respondents), role play (24 respondents) and small group activities (20 respondents) into their next teaching session. In our second workshop, there were 19 participants who had also attended the first workshop. All 19 of these residents reported using at least one active teaching technique during the previous year, and over half reported using at least three of the techniques.

Discussion: Participants reported high levels of satisfaction with the organization and efficacy of this workshop. The strategies of using sets of cards to randomize the process, adding time constraints, and having each group report their teaching plans increased overall participant interest and excitement in the workshop. Having all groups design teaching sessions using the same general topic was chosen intentionally to promote friendly competition and to allow for discussion among the groups about similarities and differences in the application of their chosen active teaching techniques. To apply our activity to other specialties, we recommend choosing general topics that are commonly encountered in that specialty; for example, the topic of “myocardial infarction” or “pediatric toxidromes” could be used for emergency medicine residents.

Audience: Clerkship-level medical students, sub-interns, junior and senior residents, attending physicians

Introduction: Bite injuries and envenomation are core content found in the model of the clinical practice of emergency medicine.1 However, depending on the geographic location of training or clinical practice, physicians may or may not be exposed to these pathologies. For example, a qualitative analysis conducted in 2022 discovered a significant range in emergency medicine (EM) physician perception of snake antivenom use and level of comfort, noting that experiences with its use ranged from hundreds of cases treated to purely didactic understanding.2 Such discrepancies necessitate supplemental education and activities to bridge the knowledge gap. Ideally, these activities would utilize tenets of experiential learning to allow learner processing comparable to that of clinical experience.3 Flipped classroom and audience participation promote engagement and active learning when compared to the passive learning of lectures.4 In that vein, there is a growing body of gamified resources in medical education which utilize pattern recognition and problem solving skills that can be analogous to clinical practice.5,6

Educational Objectives: By the end of this activity, learners will be able to: 1) identify and name species responsible for bite/sting/envenomation injuries, 2) recognize associated signs, symptoms, physical exam findings and complications associated with bites/stings/envenomations by certain species, 3) discuss management such as antibiotics, antivenom, and supportive care.

Educational Methods: We designed a small group activity asking residents to identify, research, and present the “culprits” implicated in environmental exposures to animals and insects, and match them to corresponding clinical scenarios.

Research Methods: Participants anonymously answered electronic multiple-choice quizzes before and after completing the activity to gauge its effectiveness in conveying the material. They also completed an

additional anonymous, electronic survey regarding their attitudes towards this activity and the possibility of other gamified didactics within the curriculum.

Results: Each resident class showed an upward trend in their average multiple-choice score, the greatest of which was seen in the post-graduate year (PGY) 1 class. The residency demonstrated a statistically significant improvement in their ability to answer multiple choice questions (MCQs), with an average pre- activity score of 67.14%, and post-activity score of 87.14%. Participants showed determination and enthusiasm to engage with the material when presented in a gamified format, and 100% of post-activity survey respondents wanted to participate in further gamified activities.

Discussion: Gamified small group activities are a fun and effective method of supplementing residency and medical student education for both common and esoteric clinical presentations that they may not encounter in the clinical environment.

Audience: This is an in-person escape room and procedure simulation activity based on complications of human immunodeficiency virus (HIV) in India, which was created by using local HIV management guidelines. Emergency Medicine (EM) trainees of all post-graduate levels are the target audience. This may also be used by trainees in other specialties, such as infectious disease or internal medicine, who require an understanding of HIV and its complications. This escape room can be completed in teams of varying sizes and is designed to be adaptable to local resource availability.

Background: Patients with HIV present to the Emergency Department (ED) for a variety of reasons such as initial viral syndrome, medication side effects, and opportunistic infections. While the widespread use of antiretroviral therapy (ART) has significantly increased the life expectancy of patients living with HIV and decreased the incidence of classical opportunistic infections, EM providers should still be vigilant and competent in diagnosing and managing these pathologies. This is particularly critical in India, where the prevalence of HIV was most recently estimated at 0.22% (2.2 million people older than 15 years) in 2020.1 This patient population, primarily infected through unprotected heterosexual contact, is at high risk for interruptions in ART and development of opportunistic infections for a variety of reasons including migration for work, low social status of women, and significant social stigma against HIV.2 Simulation is an educational opportunity to review these high-acuity low-occurrence presentations to prepare EM trainees for independent practice.

Educational Objectives: By the end of the escape room, learners should be able to: 1) describe the mechanism of action of antiretroviral therapies available in India, 2) prescribe initial antiretroviral therapy to

a patient presenting to the emergency department with a new diagnosis of HIV, 3) develop a differential diagnosis for a patient with HIV presenting to the ED with chest pain, 4) identify common dermatologic manifestations of opportunistic infections in patients with HIV, 5) identify computerized tomography scan and lumbar puncture features for central nervous system infections seen in patients with Acquired Immunodeficiency Syndrome (AIDS), 6) identify red flag features and appropriate workup for a patient with HIV presenting with a headache to the ED, 7) interpret images obtained during a Rapid Ultrasound for Shock and Hemorrhage (RUSH) exam, 8) identify cardiac tamponade and perform a pericardiocentesis, and 9) communicate and collaborate as a team to manage a complex, unstable patient with HIV in the ED.

Educational Methods: We sought to create and implement an educational tool that could meet the complex education needs of EM trainees while being low cost, easily adapted to local resources, and engaging for trainees. Hospitals participating in the Masters in Emergency Medicine (MEM) program, a global partnership between the Ronald Reagan Institute for Emergency Medicine at the George Washington University and 18 hospitals in India, have resource variability for traditional simulation. The escape room created combines simulation, content review specific to the contextual practice of EM in India focused on HIV and its complications, and critical procedure teaching on pericardiocentesis. This innovation framework is based on Kolb’s experiential learning cycle and incorporates the gamification principles of a sense of autonomy, perception of competitiveness, and learner-relatedness.3-4 Escape rooms have been shown to engage learners, and low-fidelity procedure models could further maximize the experience for learners in resource variable settings.5 A pericardiocentesis model was adapted from Lord et al.’s low-fidelity model, ensuring it could be assembled with materials readily available in-country.6

Research Methods: We adapted the escape room format to combine simulation, content review, and procedural training in a cost-effective, contextually relevant, and scalable way. The escape room was trialed using a case of chest pain and altered mental status caused by a pericardial effusion due to tuberculosis in a patient with HIV. Local practice patterns and guidelines were used to develop puzzles and clinical clues. A pericardiocentesis model was constructed using materials readily available in India. Pre- and post-surveys were developed to assess baseline trainee experience with escape rooms, self-reported knowledge of the differential diagnosis and management for altered mental status, and ways to incorporate escape room content into daily practice.

Results: A total of 47 trainees participated; 41 of 47 participants completed both pre- and post-surveys (87% response rate). Participants represented all program trainee levels: 49% (n = 20) PGY-1, 27% (n = 11) PGY-2, and 24% (n = 10) PGY-3. Based on a score greater than seven on a 1-10 Likert scale, the escape room was rated as “highly effective” by 93.5% of respondents in reviewing medical knowledge. The trainees were allotted 60 minutes to escape the room; the median time for escape room completion was 57 minutes. The escape room and pericardiocentesis model cost under $100 USD, were repeated up to six times in one day, and could be recycled for future use.

Discussion: Utilizing simulation in the escape room format that can be adaptable to variable resource settings is a valuable educational tool. The integrated escape room and procedure training proved to be an effective educational tool that was scalable and maintained efficacy across variable hospital resource levels. The next step includes adapting this format for other disease pathologies. This is a useful way to meet the education needs of MEM program trainees, regardless of hospital resource availability, that could be replicable in other EM training programs.

Audience: Emergency medicine (EM) residents. This simulation curriculum may also be utilized for senior medical students conducting EM rotations.

Background: Ophthalmologic education represents only a small portion of medical school curriculums and continues to decrease over time, leaving physicians poorly equipped to diagnose and manage eye complaints.1 Of emergency physicians (EPs) surveyed, 72.5% felt that they could diagnose orbital compartment syndrome (OCS), yet only 40.3% felt comfortable performing a necessary lateral canthotomy and cantholysis (LCC).2 These survey results demonstrate the urgent need for improved ophthalmology education in EM residency to help us diagnose and manage potentially vision-threatening pathology.

Educational Objectives: By the end of this simulation, learners will be able to: 1) demonstrate the major components and a systematic approach to the emergency ophthalmologic examination, 2) develop a differential diagnosis of sight-threatening etiologies that could cause eye pain or vision loss, 3) demonstrate proficiency in performing potentially vision-saving procedures within the scope of EM practice.

Educational Methods: Low-fidelity simulation was conducted using a novel model adapted from that used by Phillips et al. during their ophthalmology day in the Department of Emergency Medicine at Vanderbilt University.3 The simulation case was developed by an interdepartmental team of ophthalmologists and EPs at our institution.

Research Objectives: To evaluate for statistically significant changes in self-efficacy, knowledge, and performance after an educational intervention. Our primary outcome was defined as a checklist-based performance on a simulated case of orbital compartment syndrome necessitating LCC.

Research Methods: We conducted a single-center prospective pre- and post-interventional study evaluating the impact of an educational intervention on EM resident management of a simulated case of OCS. Our two- part study intervention consisted of a lecture on OCS followed by a four and a half hour ophthalmology education day (OED). Residents were evaluated using self-efficacy scales (SES), multiple-choice questions (MCQ), and a performance checklist (developed via a modified Delphi process) at three timepoints: Pre- intervention, immediate post-intervention, and three months post-intervention. Post-graduate year (PGY)-1 through PGY-4 EM residents at an Urban Level 1 Trauma Center participated.

Results: Initial recruitment consisted of 18 residents (PGY-1 through PGY-4), and 16 residents (PGY-1 through PGY-3) completed the study. Nine residents participated in the OED and seven residents did not. There were no pre-existing differences in median checklist-based performance, MCQ, or SES scores prior to the intervention. At three months post-OED, the OED attendees scored statistically significantly higher on checklist-based performance than non-attendees (lecture only).

Discussion: Ophthalmology education in physician training is limited, and EP comfort with performing vision- saving procedures is poor. We developed a simulation case involving such a vision-saving procedure as well as an ophthalmology curriculum that increased skill retention surrounding management of ophthalmologic emergencies.

Topics: Emergency medicine (EM), ophthalmology, orbital compartment syndrome (OCS), retrobulbar hematoma, vision loss, eye pain.

Audience: Medical students, interns, junior resident physicians, senior resident physicians

Background: Power outages have been increasing in frequency in the past few years, therefore becoming an increased threat to healthcare delivery.1 While most studies related to the effects of power outages are focused on outpatient care, such as acute exacerbations of chronic lung conditions and the lack of chargeable equipment, with the increasing number of power outages, hospitals must be prepared for this situation as well.2,3 Although agencies such as the Federal Emergency Management Agency (FEMA) and the US Department of Health and Human Services (HHS) have provided guidelines for the response of hospitals to temporary loss of power,12,13 hospitals generally rely on institutional policies in response to the event of a power outage. Given the relative rarity but increasing frequency of power outages in hospital settings, this medical simulation was created to present a common occurrence in the emergency department (eg, cardiac arrest) in an uncommon setting of a power outage. Simulation has been shown to improve learner self- efficacy, confidence, and leadership skills among resuscitation teams.4,5 The role of simulation also helps learners identify latent safety threats, in this case a power outage.6 The goal of this simulation is to improve the skills of healthcare professionals with regards to managing cardiac arrest and to encourage these practitioners to consider their own hospital guidelines in response to a power outage.

Educational Objectives: By the end of this simulation, learners will be able to (1) evaluate and treat a patient experiencing myocardial infarction and subsequent cardiac arrest during a power outage, (2) describe the local protocols for managing patient care during a power outage, (3) demonstrate the ability to coordinate a medical team during a simulated power outage in an emergency department with limited resources, (4) manage a cardiac arrest patient by following Advanced Cardiac Life Support (ACLS) protocols for bradycardia and ventricular fibrillation, and (5) justify the urgency of transfer to a certified ST segment elevation myocardial infarction center/cardiac intensive care unit, referencing the recommended 120-minute door-to- balloon time.

Educational Methods: This simulation was conducted with a high-fidelity mannequin. A total of six residents of various post-graduate year (PGY) levels participated in the simulated patient encounter as part of the simulation competition at the Western Regional meeting of the Society for Academic Emergency Medicine.

Research Methods: This case was assessed for educational content and piloted by emergency medicine attendings from several institutions prior to running the case for the Western Regional meeting. The efficacy of the content was assessed by oral feedback.

Results: The case was well-received by both the attending physicians who evaluated the case prior to running the scenario at the Western Regional meeting and the emergency medicine residents who participated in the case at the Western Regional meeting.

Discussion: Overall, this simulation was well received by both the learners and the debriefers. General feedback was positive, with the perception of increased confidence among learners and reflection upon individual hospital policy in the event of a power outage.

Audience and Type of Curriculum: This is a review curriculum utilizing multiple methods of education to enhance the skills of generalist healthcare providers in low- and middle-income countries (LMICs) in the identification and stabilization of pediatric respiratory emergencies. Our audience of implementation was Belizean generalist providers (nurses and physicians).

Length of Curriculum: 8-10 hours

Introduction: Early recognition and stabilization of critical pediatric patients can improve outcomes. Compared with resource-rich systems, many low-resource settings (i.e., LMICs) rely on generalists to provide most pediatric acute care. We created a curriculum for general practitioners comprising multiple educational modules focused on identifying and stabilizing pediatric emergencies. Our aim was to develop an educational framework to update and teach generalists on the recommendations and techniques of optimally evaluating and managing pediatric nutritional and gastrointestinal emergencies: bowel obstructions, gastroenteritis, and malnutrition.

Educational Goals: The aim of this curriculum is to increase learners’ proficiency in identifying and stabilizing acutely ill pediatric patients with gastrointestinal medical or surgical disease or complications of malnutrition. This module focuses on the diagnosis and management of gastroenteritis, acute bowel

obstruction, and deficiencies of feeding and nutrition. The target audience for this curriculum is generalist physicians and nurses in limited-resource settings.

Educational Methods: The educational strategies used in this curriculum include didactic lectures, medical simulation, and small-group sessions.

Research Methods: We evaluated written pretests before and posttests after intervention and retested participants four months later to evaluate for knowledge retention. Participants provided qualitative feedback on the module.

Results: We taught 21 providers. Eleven providers completed the pretest/posttest and eight completed the retest. The mean test scores improved from 8.3 ± 1.7 in the pretest to 12.2 ± 2.6 in the posttest (mean difference: 1.4,

ABSTRACT:Early diagnosis of rheumatologic diseases can improve patient outcomes. While clinical presentations of rheumatologic diseases can be vague, dermatomyositis (DM) has distinctive cutaneous findings that can clue in providers towards the diagnosis. This is a case report of a 49-year-old female who presented with progressive facial swelling, rash, and generalized myalgias for a month. She had seen several outpatient providers and had one other emergency department (ED) visit for these symptoms prior to her diagnosis. She had already trialed steroid creams, antibiotics, and oral steroids with no significant improvement in her symptoms. A physical exam revealed peri-orbital edema, rash on her face, chest, and arms, and proximal muscle weakness. Lab work was significant for an elevated creatine kinase (CK). Rheumatology was consulted and recommended admission for expedited work-up for DM. The DM diagnosis was confirmed, and the patient was given intravenous immunoglobulin (IVIG) and discharged on oral steroids with dermatology and rheumatology outpatient follow-up. This case exemplifies how DM is often a missed diagnosis. However, by recognizing the classic dermatologic findings, conducting a muscle strength exam, and obtaining additional laboratory studies such as CK, the diagnosis can be made more easily.

Non-obstetric vulvar hematoma is a rare but clinically important diagnosis in the emergency department for which there is no consensus on optimal diagnosis or management. We present a case of non-obstetric vulvar hematoma that occurred after minimal trauma in a young, otherwise healthy woman who presented with labial swelling after consensual digital penetration, initially managed conservatively but ultimately requiring surgical drainage. Although a rare presentation in the emergency department, prompt identification, diagnosis, and management of vulvar hematoma is crucial to appropriately treat complications including pain, hemodynamically significant hemorrhage, urinary obstruction, and soft tissue necrosis.