Journal of Education and Teaching in Emergency Medicine

Audience: This simulation is intended for emergency medicine residents.

Background: Lateral canthotomy and cantholysis (LCC) is a sight-saving procedure for orbital compartment syndrome (OCS).¹ Due to the rarity of OCS, emergency-medicine trainees often have limited exposure and low procedural confidence. In a questionnaire we found that trainees have low confidence levels in performing the procedure attributed to the low incidence of OCS and the scarcity of training opportunities. Existing literature describes LCC task trainers with creation of simulation models, but few provide a reproducible multimodal package adaptable for multiple training centres.^2,3 Our innovation combines presentation, instructional video, gamified quiz, and hands-on practicer with low fidelity models. Unlike previous studies referencing the use of pre-made or cadaveric-based models, this design offers detailed guidance on model assembly using commonly available and low-cost materials.^2,3 We designed and tested a multimodal training approach to optimize trainee confidence and competence in recognizing OSC and performing the LCC procedure. This aligns with recent calls in medical education for innovative, cost-effective simulation that maintains clear guidance and instructions while overcoming financial and/or logistical barriers.^4,5

Educational Objectives: By the end of this session, learners should be able to: 1) recognize the clinical features of OCS, 2) describe the indications and steps of performing LCC, 3) perform a lateral canthotomy and cantholysis procedure on a low-fidelity model, and 4) demonstrate improved confidence in recognizing and managing OCS.

Educational Methods: The training uses a multimodal structure involving the following resources: 1) Instructor-led presentation on OCS and LCC with a step-by-step guide (Appendix A), 2) gamified quiz (Appendix B), 3) a procedural demonstration video, 4) a procedural handout containing a step-by-step guide (Appendix C), 5) a low-fidelity model of the orbit constructed from inexpensive materials, and 6) hands-on procedural practice with trainer feedback. 

Research Methods: Trainees’ confidence and perceived competence in performing the procedure were assessed using a 10-point Likert scale before and after the training, in addition to collection of qualitative feedback via free-text comments. Trainees also rated all educational components of the course using a 10-point Likert scale. Statistical significance was calculated using paired t-tests. 

Results: A total of thirty-four emergency medicine trainees participated in this multi-national training simulation package across three centers within the UK, completing pre- and post-intervention feedback. We observed a significant improvement in participants’ self-assessed confidence levels when comparing theoretical knowledge (5.0 ± 2.5 to 8.7 ± 1.7; p < 0.0001) and procedural competence (4.1 ± 2.8 to 8.9 ± 1.5; p < 0.0001). All educational components of the training package were rated highly, with mean scores ranging between 8.7 and 10 (measured on a 10-point Likert scale). All trainees involved supported the idea of annual delivery of the training package to emergency medicine trainees. Qualitative feedback further supported the value of practical simulation.

Discussion: Given the severe clinical consequences of OCS, there is a need for diagnostic and procedural competence. This training package demonstrated significant improvement in trainees’ confidence and competence for a rare but critical emergency department procedure. The low-fidelity model and simulation package is reproducible, cost-effective, and scalable across training centres.

Audience: This virtual escape room (VER) serves as a didactic activity tailored for learners specializing in emergency medicine, pediatrics, and family medicine across all postgraduate years. The VER can be undertaken collaboratively in teams or individually, leveraging virtual platforms and adaptable to various educational settings.

Introduction: Iron tablets appeal to children due to their vibrant color and sugar coating, resembling candy. Nearly 11,000 cases of iron exposure in children under six are reported annually in the US.¹ More severe incidents involve prenatal vitamins and iron preparations containing ferrous sulfate, which has a significantly higher concentration of elemental iron per tablet than other formulations.² Virtual escape rooms (VERs) are an innovative educational tool for teaching about acute iron toxicity. By integrating gamification into medical education, VERs offer a unique approach asparticipants can join remotely and interact with a team of other learners in geographically distinct locations.

Educational Objectives:

By the end of the activity, learners should be able to: 1) recognize the history and clinical presentation of acute iron toxicity; 2) demonstrate knowledge of the necessary workup in suspected iron toxicity; 3) identify the stages of acute iron toxicity; 4) identify management of iron toxicity and its complications; 5) perform appropriate management in the setting of decompensated hemorrhagic shock and hypovolemia; and 6) demonstrate teamwork through communication and collaboration.

Educational Methods: The development process encompassed a seven-step approach: creating a scenario, defining learning objectives, and designing a suitable room.³ Clues and puzzles aligned with the specified learning objectives. The VER was hosted on Articulate 360 (Articulate Global Inc.) and complemented by a facilitator guide that provided content and technical support.

Research Methods: To replicate this activity, a team of facilitators should be present to organize the participants into small groups and distribute the VER link. During our implementation, this link was shared in real-time on Zoom Video Communications Inc. (Zoom), leveraging breakout rooms to assign participants to their respective rooms. Additionally, we conducted this in person with faculty and nursing, where participants were divided into groups accordingly. There was a structured format: pre-briefing, a timed escape room scenario, debriefing, and evaluation. Afterward, learners evaluated the VER and educational content with a survey hosted on Google Docs (Google LLC). 

Results: A total of 55 respondents completed post-evaluation surveys. Despite limited experience with previous virtual escape rooms, both trainees and faculty agreed the design was easy to follow (78.2%), fostered teamwork (90.9%), and was a feasible method of education (85.5%). 

Discussion: This activity was successfully implemented with trainees, faculty, and nursing professionals, demonstrating the ability of VER to be utilized in a wide variety of applications. We also successfully implemented this format in both in-person and online platforms. Limitations of this include a need for long-term outcome data. Future studies could further assess knowledge improvement and clinical management of acute iron toxicity. 

Topics: Acute iron toxicity, emergency medicine, escape room, ingestion, gamification, pediatrics, toxicology, virtual escape rooms.

Audience: This session is intended for first- and second-year medical students, or any pre-clinical medical students.

Introduction: Preclinical learners build skills and confidence when they practice first responder tasks early in training, and simulation helps them to perform basic procedures better.^1,2 A small group case competition uses a game format to reinforce rapid assessment, clear team roles, and closed-loop communication.^3,4

Out-of-hospital cardiac arrest affects hundreds of thousands of people in the United States each year, and survival to discharge is low. Bystander cardiopulmonary resuscitation (CPR) and early use of an automated external defibrillator (AED) improve outcomes.^5,6 Anaphylaxis is a time-sensitive emergency seen in the community and in the emergency department (ED). Epinephrine is the first-line treatment, and delay to administration worsens outcomes.^7,8 Opioid overdose remains a major cause of preventable death. Early recognition, respiratory support, and Naloxone administration are key steps.⁹ 

Educational Objectives: By the end of this activity, learners will be able to: 1) demonstrate the application of skills in real-life first responder scenarios, including suspected opioid overdose, cardiac arrest, and anaphylaxis; 2) apply knowledge of scene safety and the role of the first responder in various situations; and 3) assess the challenges while applying the skills necessary for collaborative work within a medical team.

Educational Methods: A competition combining simulation-based and team-based learning reinforced first responder skills among first- and second-year medical students. Attending physicians evaluated simulated out-of-hospital emergency scenarios using a detailed rubric. This method was chosen to engage learners in a lower-stakes (but still simulated high-pressure) assessment of their skills where undifferentiated patients challenge recall and application in new, previously unknown scenarios.

This format was chosen to keep preclinical students active and focused while they practice time-critical first responder skills. Simulation allows decision-making, hands-on actions, and immediate feedback in a safe setting. Team-based learning mirrors ED teamwork by assigning clear roles, prompting closed-loop communication, and requiring shared problem-solving. Station design supports repeated practice and brief debriefs, which builds retention and confidence for early learners. Faculty-scored rubrics provide observable, standardized performance measures and make feedback specific and actionable. 

Research Methods: Pre- and post-intervention surveys assessed the effectiveness of the case competition featuring three simulation scenarios in improving students' confidence in managing emergency situations.

Results: The competition increased participants' confidence in responding to various scenarios, particularly opioid overdoses. Most participants expressed high likelihood of participating in future competitions. Ten preclinical students completed pre- and post-session surveys. Confidence increased across the cohort. For the opioid overdose scenario, “complete confidence” rose from 1/10 (10%) pre- to 6/10 (60%) post. Confidence in cardiac arrest and anaphylaxis also trended upward. Likelihood to respond to a public emergency changed minimally. Interest in future events was high, with 6/10 (60%) extremely likely and 4/10 (40%) somewhat likely to participate again. 

Discussion: The competition successfully increased confidence and fostered collaboration but faced recruitment challenges due to its optional nature and scheduling. Future implementations could include more advanced learners.

Audience: This card game is designed to cultivate educational discussion among emergency medicine resident physicians about the assessment, treatment, and disposition of key pediatric and adult thoracic-respiratory diagnoses in a fun, casual environment. It could also be played by emergency medicine-bound medical students.

Introduction: Emergency department visits related to the thoracic-respiratory system are common complaints in both the pediatric and adult populations. In the United States, for several years prior to the Covid-19 pandemic, respiratory system diseases accounted for about 10.6% of ED visits.¹ In children, respiratory complaints make up the largest percentage of their ED visits, particularly in the fall and winter seasons.² This number appears to have only grown higher in both adults and pediatrics in the years following the Covid-19 pandemic.³ Thoracic-respiratory disorders also account for about 7% of the American Board of Emergency Medicine In-Training Exam  and qualifying exam content.⁴ Therefore, it is paramount that resident physicians understand the presentation, management, and treatment of a wide range of both pediatric and adult thoracic-respiratory complaints and pathology that mimics these presentations. This game explores key topics in the thoracic-respiratory system in both the pediatric and adult populations allowing for fun discussion regarding management, treatment, and disposition of these complicated disease processes. Topics range from sick to not sick patients and include bronchiolitis, pulmonary edema, pulmonary embolism, COPD exacerbation, neonatal cyanosis, viral upper respiratory infections, and more.  

Educational Objectives: 

By the end of this card game, learners will 1) understand the methods of clinical assessment in thoracic-respiratory related diseases, 2) implement escalating levels of respiratory support for thoracic-respiratory pathology in pediatric and adult patients, 3) review and utilize important medications in the management of thoracic-respiratory diseases, and 4) choose appropriate dispositions of patients with various thoracic-respiratory related complaints. 

Educational Methods: The goal of Cards Against Pulmonology is for learners to further understand the clinical assessment, management, and disposition of various thoracic-respiratory emergencies by providing the next best critical action in a given clinical situation. This game will equip residents to differentiate the sick from non-sick patients and collaboratively discuss the management and disposition of patients with a variety of thoracic-respiratory related complaints.

This card game is a cognitive artifact designed to stimulate small group discussion that will enhance the clinical reasoning skills of the medical students and resident physicians who play the game. The clinical content of thoracic-respiratoryconditions has been gamified through the strategy of play modeled after the popular card game, Cards Against Humanity. Discussion of key educational points during and after the game provides clarification of learner knowledge to solidify concepts. 

Research Methods: The game was implemented in a weekly resident educational conference session where 19 resident physicians and several faculty physicians participated in gameplay and immediately following the game, evaluated the educational experience by survey using a Likert scale. They assessed their overall experience with the game, engagement with the game, the game’s ability to reinforce existing medical knowledge, and if game content was relevant to their clinical practice. 

Results: The results were overwhelmingly positive with an average of strongly agreed on every Likert scale in every category and a request for the creation of other similar games covering more topics. Resident physicians stated they appreciated being able to laugh and learn, and that the inclusion of case discussion after a case concluded really emphasized the educational points regarding the medical care of patients with respiratory complaints. They encouraged increased discussion of the medicine after each round. 

Discussion: Overall, this game was very effective in stimulating conversation regarding the care of patients with thoracic-respiratory related complaints. All medical students, residents, and attending physicians were very engaged and remained excited throughout gameplay. Implementation of the game showed the appropriate small group size is about five to six players to allow for robust discussion and engagement. It is also important for the facilitators to discuss expected outcomes for the patient at the conclusion of a set of case cards to encourage educational value alongside humorous game play. 

Topics: Pulmonology, thoracic-respiratory system, shortness of breath, cough, viral respiratory infection, bronchiolitis, asthma, COPD, pulmonary edema, pediatric respiratory conditions.

Audience: This small-group simulation workshop is designed for pediatric emergency medicine fellows but can also be offered to emergency medicine residents or faculty.

Introduction: Pediatric intubation is a high-acuity, low-frequency event. Specific patient scenarios that may lead to a difficult pediatric airway, such as airway edema, airway contamination (hemorrhage, emesis), prematurity, obesity, shock, and inhalational injuries, compound an already challenging and emergent situation. Previous studies have investigated simulation-based airway education for emergency medicine (EM), anesthesia, and critical care trainees. To our knowledge, there has been no study reporting the development and outcomes of a difficult airway course for pediatric emergency medicine (PEM) fellows covering emergency department (ED)-specific pediatric difficult airway content. 

Educational Objectives: The objective of this one-day simulation workshop is to increase learner confidence and skills necessary to perform critical pediatric airway procedures. PEM fellows of all training levels at our institution completed a three-hour “PEM Difficult Airway Day,” which consisted of six 30-minute stations focusing on airway scenarios critical for PEM fellow training: five high- and low-fidelity simulations (premature neonate, inhalational injury, contaminated airway, obese patient, and failed airway) and one discussion-based station on the physiologically difficult intubation. By the end of this workshop, learners will be able to: 1) identify various clinical situations in which a pediatric patient may have a difficult airway, 2) successfully intubate mannequins with simulated difficult airways using direct laryngoscopy (DL), video laryngoscopy (VL), laryngeal mask airway (LMA) placement, bougie-assisted intubation, and a hyper-angulated VL blade, and 3) recognize and describe the management of physiologically difficult airways and failed airways. 

Educational Methods: Small group activity combining procedural high- and low-fidelity simulations, as well as case-based learning.

Research Methods: The PEM fellows completed pre- and post-workshop surveys to assess their airway knowledge and confidence regarding intubation using DL, VL, LMA placement, bougie-assisted intubation, intubation using a hyper-angulated VL blade, managing the anatomically difficult airway, managing the physiologically difficult airway, and managing the failed airway. In addition, learners were asked to identify any areas with continued knowledge gaps and low procedural confidence that they wished to be addressed in a future “PEM Difficult Airway Day.” 

Results: Our findings suggest that the “PEM Difficult Airway Day” significantly improved PEM fellow knowledge and confidence in infrequently performed critical pediatric EM scenarios, such as bougie-assisted intubation and use of a hyper-angulated VL blade, and knowledge of options and techniques for managing the anatomically difficult, physiologically difficult, and failed airway. There was no statistically significant improvement in confidence in DL and VL intubation and LMA placement. Additionally, fellows identified management of airway foreign bodies as an area with a continued knowledge gap and low procedural confidence.

Discussion: A workshop dedicated to increasing the confidence and procedural skills necessary to perform critical airway procedures can be successfully offered to PEM fellows as a single-day, focused, small-group simulation workshop. 

Topics: Pediatric airway simulation, pediatric difficult airway, pediatric emergency medicine, simulation curriculum, medical education, workshop.

Orbital compartment syndrome (OCS) is an ophthalmologic emergency due to an acute rise in intra-orbital pressure and can result in permanent vision loss, oftentimes requiring emergent surgical decompression. Orbital compartment syndrome most commonly occurs due to recent trauma and is often easily diagnosed by history and physical exam. However, there are other causes of OCS where a more subacute/chronic rise in pressure can lead to an atypical presentation. This is a case report of a 48-year-old male who presented with left eye pain and swelling for the past 6 months. The patient had seen two ophthalmologists prior to his emergency department (ED) presentation who had prescribed him an antibiotic ointment, oral steroids, and steroid eye drops. The physical exam in the ED was concerning for increased intra-ocular pressure (IOP) and decreased vision. Ophthalmology was consulted and requested magnetic resonance angiography (MRA) to assess a vascular etiology given tortuous retinal vasculature. Emergent surgical decompression was deferred due to chronicity of symptoms, and patient was started on dorzolamide/timolol and brimonidine eye drops as well as intravenous (IV) acetazolamide with subsequent improvement in IOP. Imaging revealed a left carotid-cavernous sinus fistula (CCF), and the patient was admitted to neurosurgery. Patient successfully had an embolization with subsequent normalization of IOP and improvement of symptoms. This case is a good example of how non-traumatic causes of OCS can lead to misdiagnosis and how surgical decompression could potentially be deferred in subacute OCS.

We present a case of a 75-year-old female with a history of congestive heart failure who developed a large edema bulla on her right shin after running out of her home medications. The patient presented with swelling and a rapidly enlarging bulla that reached the size of a grapefruit. Physical examination revealed bilateral pitting edema and a 10 x 10 cm bulla filled with serous fluid. Dermatology was consulted, confirming the diagnosis of edema bulla secondary to acute volume overload. The bulla was drained in the emergency department, and the patient was discharged with wound care instructions, including the application of petroleum jelly and vinegar compresses. Follow-up three months later showed significant healing. This case highlights the importance of recognizing edema bullae in patients and managing the underlying fluid overload. This case report specifically demonstrates that edema bullae can present at sizes larger than the 1-5 cm range described in existing literature.

Fournier’s gangrene is a well-established surgical emergency as patients can decompensate rapidly, resulting in significant morbidity and mortality. We describe a case in which a 54-year-old medically complex male presented to the emergency department (ED) with a primary complaint of abdominal pain after a therapeutic paracentesis was performed by interventional radiology just prior to arrival. Upon further questioning, the patient reported scrotal pain that had developed over three to four days. On exam, the patient was well-appearing although he did have scattered scrotal masses with chalky white purulence. Given the relatively quick development, an atypical presentation of Fournier’s gangrene was suspected, and the patient was started on antibiotics with urology immediately consulted. Imaging was concerning for subcutaneous gas. The patient was subsequently taken to the operating room (OR) for debridement, where Fournier’s gangrene was confirmed by surgical investigation and culture. Significant lessons from the case include the importance of early identification of Fournier’s gangrene and having a low threshold to start treatment in coordination with a surgical service for atypical presentations.

This case highlights a rare and complex occurrence of an open chest wound with a pathologic sternal fracture. This resulted from a combination of remote chest trauma, chronic chest wall infection, malignancy, and ultimately, sternal osteomyelitis. A 69-year-old male presented with a large, open anterior chest wound, chronic ulceration, and weight loss. Thirty years earlier, the patient had sustained trauma from a firecracker, which led to a chronic wound for which he did not seek medical attention. Physical exam revealed a large open chest wound with an open sternal fracture and exposed pericardium. The patient underwent surgical resection, followed by chest wall reconstruction using a rectus myocutaneous flap. Tissue pathology confirmed squamous cell carcinoma and osteomyelitis of the sternum.

The case demonstrates the complexity of managing a large chronic chest wound and pathologic sternal fracture secondary to malignancy and osteomyelitis. The key lesson is the importance of early medical evaluation and a multidisciplinary approach to improve outcomes in similar scenarios. The rarity of this case emphasizes the need for heightened awareness among clinicians who may encounter earlier presentations of this disease process in order to prevent complications, such as osteomyelitis, pathological fractures and structural instability of the chest wall.  

This case report discusses a 36-year-old male who presented to the emergency department with an atypical story for acute coronary syndrome (ACS). Initially, the patient was felt to have a  non-diagnostic electrocardiogram (ECG). Once the laboratory test results were obtained and the initial high-sensitivity troponin was noted to be elevated, the initial ECG was again reviewed. The patient was felt this time to have an abnormal ECG, demonstrating borderline ST elevation in leads I, aVL, and V2-V5. The interventional cardiologist on call was contacted, and the cardiac catheterization lab was activated. Upon left heart catheterization, the patient was found to have a spontaneous coronary artery dissection (SCAD) of the distal left anterior descending (LAD) artery. Post-catheterization, the patient was observed on cardiac telemetry and started on dual antiplatelet therapy. Echocardiogram revealed a preserved ejection fraction (EF), but hypokinesis of the apical anterior, anterolateral, inferior, and apical myocardium. The patient was discharged within 48 hours without any complications.

Audience and Type of Curriculum: This electrocardiogram (ECG) curriculum was designed for residents of all levels.

Length of Curriculum: The curriculum runs over 1.5 years and is repeated, so that there will be repetition during a resident’s training.

Introduction: Electrocardiogram interpretation is a vital skill for emergency physicians. Formal ECG education in emergency medicine (EM) often consists of a few conference lectures, with the majority of education relegated to the clinical environment. However, this often leaves significant gaps in education, as a full curriculum cannot be implemented within limited conference time.

Educational Goals: The goals of the curriculum were to establish an asynchronous ECG curriculum to help improve standardization of EM resident education, expose EM residents to a more comprehensive ECG curriculum, increase active learning in this arena, and decrease the administrative burden while not dedicating further conference time towards ECG education. 

Educational Methods: The educational strategies used in this curriculum include weekly case emails with instructional content located on a Google Site. These were added to conference lectures that were standard ECG education prior to this initiative. The first year of the augmented curriculum added only the weekly ECG emails with a follow-up answer email, and the website was created for the second year of curriculum implementation. 

Research Methods: The educational content was assessed by the learners via a survey to gauge resident satisfaction as well as level of engagement and barriers to use. Additionally, the content was assessed via resident testing at the end of their second year so that they had completed a complete cycle of the curriculum.

Results: The asynchronous curriculum improved resident test scores with the addition of the weekly emails from an average of 70% and pass rate of 58% to 82% and 92%, respectively (p=0.012). The addition of the informational website did not further improve scores, though it decreased variation in scores. The residents found the curriculum useful for their education.

Discussion: Curriculum implementation was successful to improve on resident ECG education, both in terms of objective testing as well as resident feedback. It is a sustainable curriculum with methodology that requires little faculty time after setup; the maintenance required for the curriculum mostly consists of updating resident contacts as classes graduate. However, the setup time was significant; despite this, the authors believe this is a time-effective method of educational programming given the little ongoing time requirements.

Topics: Electrocardiogram, curriculum development.

Audience: This clinical decision-making (CDM) case is intended for emergency medicine residents of all levels, medical students, and fellows preparing for standardized oral board exams.

Introduction: Fever in a neonate (infant <28 days old) is a medical emergency due to the high risk of serious bacterial infections (SBIs) like meningitis, sepsis, or urinary tract infections (UTIs).^1-3 Compared with older infants and children, neonates have immature immune responses, reduced ability to localize infection, and limited physiologic reserve, which contribute to rapid clinical deterioration and increased morbidity and mortality when invasive infection is present.^1,3

Importantly, clinical presentation in this age group is often subtle and nonspecific. Neonates with life-threatening infections may appear well or only mildly ill on initial examination, with symptoms such as poor feeding, irritability, or decreased urine output serving as early but easily overlooked warning signs.¹^,4 As a result, reliance on appearance or focal examination findings alone is insufficient to safely exclude SBI in febrile neonates.

Current evidence supports a standardized approach to the evaluation of neonatal fever. This includes a complete sepsis workup—consisting of blood, urine, and cerebrospinal fluid studies—along with early administration of empiric, age-appropriate intravenous antibiotics and hospital admission for close monitoring.¹^-³

This clinical decision-making case is designed to reinforce these foundational principles within the context of an emergency department presentation. It emphasizes early recognition of neonatal fever as a high-risk condition, systematic diagnostic reasoning, timely initiation of empiric therapy, and appropriate disposition to a higher level of care. Learners are challenged to clearly articulate their clinical reasoning and management decisions in a high-stakes environment that mirrors real-world emergency medicine practice.

Educational Objectives: By the end of this CDM case, learners will be able to: 1) demonstrate familiarity with the CDM case format, 2) recognize the critical importance of fever in a neonate and initiate a thorough evaluation, 3) develop an appropriate differential diagnosis and understand the workup for febrile neonates, 4) identify and justify the appropriate diagnostic studies and interpret their findings in the context of a neonate with fever, 5) justify a treatment plan and understand the critical disposition of a neonate with fever.

Educational Methods: The case will be presented as a CDM case with questions posed by the examiner. Learners will be asked to list the history, physical exam findings, differential diagnosis, diagnostic studies, treatments, and final diagnosis in response to the examiner’s prompts.

Research Methods: Learners' performance will be evaluated using standardized oral board scoring guidelines. Efficacy will be assessed through feedback from both learners and faculty, focusing on knowledge acquisition and application in a high-stakes environment. Pre- and post-case surveys or performance scoring may be used for evaluation.

Results: Preliminary assessments from learners demonstrated improved confidence in managing febrile neonates after completing the case, with a focus on early recognition and appropriate escalation of care.

Discussion: Neonatal fever is a high-risk scenario requiring prompt, appropriate management. This case reinforced the importance of early sepsis recognition, comprehensive evaluation, and timely treatment. Learners benefited from exposure to the CDM Case format aiding in their exam preparation.