Journal of Education and Teaching in Emergency Medicine

Audience: This is a combined independent study and simulation session designed to teach and drill Mass Casualty Incident (MCI) Triage and is intended for emergency medicine residents at all levels.

Introduction: The training of emergency medicine residents to assume leadership roles in disaster response is important. However, lack of accepted specific educational goals on the national level leads to significant variability between residencies.

Educational Objectives: The purpose of this session is to train EM residents in the use of the Simple Triage and Rapid Treatment (START) and pediatric JumpSTART algorithms for triage in mass casualty incidents (MCIs) using an asynchronous model. By the end of this small group session, learners will be able to: 1) describe START triage for adult MCI victims; 2) describe JumpSTART triage for pediatric MCI victims; 3) demonstrate the ability to apply the START and JumpSTART triage algorithms in a self-directed learning environment; 4) demonstrate the ability to apply the START and JumpSTART triage algorithms in a simulated mass casualty scenario under time constraints; and 5) demonstrate appropriate use of acute life-saving interventions as dictated by the START and JumpSTART triage algorithms in a high-pressure simulated environment.

Educational Methods: This session utilizes an online independent study module that was created de novo for this specific purpose by the authors followed by a high-pressure in-person simulation session where learners practice applying the START triage model with multiple simulated patients under time constraint.

Research Methods: Learner feedback was collected after completion of the session. Retention of learning objectives was tested at four months via multiple-choice quiz.Results: The session was very well received by our residents, who appreciated the opportunity to practice applying START triage under pressure. The average score on the pretest was 49%. Response rates to the post-test were low, but residents scored an average of 73%, indicating a trend towards retention of learning objectives.

Discussion: Overall, the utilization of a de novo online learning module followed by simulation proved to be a well-received method of teaching MCI triage to emergency medicine residents. We consider this to be an effective way to train MCI Triage with minimal in-conference time utilization. We plan to implement this training annually to provide our residents with longitudinal reinforcement of this vital skill.

Audience: This case-based virtual escape room (VER) serves as a didactic activity suitable for learners who require an understanding of organophosphate toxicity. Educators may use this VER for distance-based learning in settings with adequate internet access.

Introduction:

India faces a concerning escalation in suicide rates, particularly among teenagers and young adults, often involving intentional pesticide ingestion, notably organophosphates.1-3 Our project addresses organophosphate ingestion by using a VER, a virtual learning platform adapted from in-person escape rooms to engage participants for educational purposes.4,5 Demonstrating success in medical, pharmacy, and nursing education, VERs increased satisfaction and competency among healthcare trainees compared to traditional learning platforms while fostering teamwork and communication in a virtual learning environment.6,7

Educational Objectives:By the end of the activity, learners should be able to: 1) recognize risk factors, symptoms, and presentation for organophosphate poisoning; 2) understand the radiologic and laboratory findings in organophosphate poisoning; 3) distinguish and differentiate electrocardiogram findings in common toxic ingestions; 4) explain the pathophysiology of organophosphate poisoning; 5) understand the importance of decontamination of the patient and personal protective equipment for staff for organophosphate poisoning; 6) describe the airway management of organophosphate poisoning; 7) describe the medical management of organophosphate poisoning, including antidotes and the correct dosing and 8) demonstrate teamwork through communication and collaboration.

Educational Methods: The development process involved a seven-step approach, beginning with topic selection. The process involved creating a scenario, defining learning objectives, and designing an appropriate room. Clues and puzzles were tailored to align with the learning objectives and promote interactivity. The VER was hosted on Google Sites (Google LLC), accompanied by a facilitator guide offering content and technical support.

Research Methods: This VER leverages technology for distance learning, using Zoom (Zoom Video Communications Inc.) for online sessions with EM trainees. Participants were organized into small groups in breakout rooms on Zoom, following a structured format that included a pre-briefing, a timed escape room scenario, debriefing, and evaluation. Afterward, an evaluation in the format of a survey was distributed to participants. This study was Institutional Review Board exempt.

Results: Out of 120 participants in the VER, 50% responded to a survey. The majority found the activity interactive, engaging, and exciting. This feedback indicated a positive reaction to the VER, consistent with the Kirkpatrick model's first level of assessment.8 The VER effectively promoted learning and reinforced clinical knowledge, contributing to the second level of the Kirkpatrick model. In this case, 84.7% of respondents were able to identify knowledge gaps, and 84.2% of respondents found this to be a feasible model to reinforce medical knowledge.

Discussion: This innovative VER addresses the value of distance-based learning in any setting with an internet connection. It has successfully enhanced collaboration and communication among participants in small groups, making it a valuable resource for medical education. This study has several limitations worth noting including a relatively low survey response rate. Baseline data was not collected prior to the VER. Additionally, the VER was not designed to be an open-book assessment; however, the absence of an in-person moderator makes it challenging to ascertain whether participants used external resources. Furthermore, the exclusive focus of this VER on a single topic may diminish its overall use compared to more traditional didactic sessions. This study is also limited by lack of long-term outcome data. Future studies could further assess knowledge improvement and clinical application. The authors plan to develop additional case-based VERs to advance EM trainees' knowledge, skills, and communication. Overall, the VER offers a promising and free educational tool for distance learning with potential benefits for various settings with internet access.

Audience: This small-group workshop is designed for pre-clinical medical students. The workshop can also be offered to other medical students looking to review first aid in the community setting.

Introduction: First aid training in medical students varies based on each student’s previous experience. Because of this, medical students in their pre-clinical years have expressed a desire for further training in first aid.1 While most bystanders in an emergency situation do not have a medical background, medical students have received additional training that can provide the skillset to process and respond to emergency situations in a different capacity. Most medical schools have not adopted a universal curriculum in teaching medical students first aid.2 Incorporating first aid into a medical school curriculum can enhance medical students’ confidence in emergent situations and lead to better outcomes for patients requiring immediate on-site care.

Educational Objectives: The goal of this workshop was to improve the confidence of medical students in handling emergencies in the community with the use of first aid while also giving them a standard approach to emergencies using an airway, breathing, and circulation approach. The curriculum was evaluated through student-perceived self-efficacy and confidence in handling the provided scenarios, performance on relevant multiple choice questions, and general appeal of the first aid sessions. By the end of this workshop, students will be able to define the goals of “first aid” and first responder actions, describe clinical signs and symptoms suggestive of an airway, breathing, or circulation emergency in the setting of selected medical emergencies, and demonstrate immediate care steps in the setting of selected medical emergencies, specifically the Heimlich maneuver on adults and infants, direct pressure, wound packing, tourniquet application for external bleeding, epinephrine auto-injector administration, and the recovery position for obtunded or unconscious patients.

Educational Methods: Small group activities were performed with a focus on case-based scenarios combined with hands-on instruction. The four scenarios were choking, seizure, anaphylaxis, and bleeding which were taught by an educator who was either faculty, an emergency medicine resident, or an upper-level medical student. Facilitators were provided an educational handout specific to their station to guide them through

the teaching session. A PowerPoint presentation was also provided complete with supporting images and videos to share with the students each session.

Research Methods: Students were asked to complete a pre-test and post-test survey to assess knowledge outcome, self-efficacy in first aid, and overall appeal of the workshop. The multiple-choice knowledge outcome data was scored for percent correct on each question as well as overall performance on questions grouped by content. Students were also asked to provide feedback and comments on their overall experience in the workshop.

Results: Overall, medical students reported increased knowledge and confidence in responding to various first-aid situations. There was overall improvement in pre-test and post-test evaluations. The appeal of the event as a whole and its usefulness was overwhelmingly viewed as positive. Some participants noted they wanted similar workshops with more first-aid topics. Participants also noted they felt better prepared to respond to the various emergencies included in the workshop.

Discussion: A workshop directed at teaching first aid to medical students increased their confidence and knowledge in responding to various emergencies and can successfully be accomplished through a focused large group didactic session and multiple clinically relevant small group teaching sessions.

Audience: This case was designed for emergency medicine interns and residents.

Introduction: Human trafficking is unfortunately an ever-growing and wide-reaching problem in the United States as well as the rest of the world. The International Labor Organization estimates 49.6 million people were affected by this modern-day slavery worldwide in 2021.1,2 The emergency department represents an opportunity to identify and provide aid to victims of human trafficking. Studies have shown that 63.3% of survivors interacted with the emergency department during their time of exploitation; however, most of these patients are not identified as human trafficking victims and opportunities for intervention are missed.3,4

Educational Objectives: By the end of this simulation, participants will be able to: (1) Identify signs of human trafficking. (2) Demonstrate the ability to perform a primary and secondary assessment of a patient when there is concern for human trafficking. (3) Demonstrate the ability to appropriately separate an at-risk patient from a potential trafficker. (4) Identify resources and a reliable course of action to permanently remove the patient from the harmful situation.

Educational Methods: A hybrid teaching model was employed that included both a lecture and a standardized patient simulation session followed by a structured debriefing session.

Research Methods: A simulation with a standardized participant was implemented at an urban academic emergency department with a three-year EM residency program. Participants were evaluated with a survey prior to and after the simulation, where they responded to questions regarding human trafficking patients on a scale of 1 to 5, where 5 represented the greatest level of agreement. Nineteen emergency medicine interns and residents participated in this project.

Results: Prior to simulation training, and after the lecture, residents were surveyed on their confidence in identifying and treating patients who are affected by trafficking, their level of previous training in this topic, and whether they considered trafficking an important issue in emergency medicine. When asked if human trafficking is an important issue faced by the emergency department, 15 of the 19 of residents who completed the survey rated the importance a 5/5 on a Likert scale ranging from 1-not important to 5. Residents were also asked if they had received prior training in human trafficking on a scale of never (1) to often (5). Eight residents responded with either never or close to never. Two months after the simulation, the residents were again sent an optional survey. Ten residents responded. All who participated in the simulation now rated themselves a 4/5 on a scale from not confident to very confident. Of those who did not attend the simulation, the median value was a 3/5. Out of the residents who attended the simulation training, every resident rated the experience 5 out of 5 in terms of usefulness. One hundred percent of residents would recommend simulation training on human trafficking to other emergency medicine residents.

Discussion: This was an effective educational initiative because this education model allowed the residents to feel more comfortable identifying individuals affected by human trafficking, and all the residents who responded to the survey stated that they would recommend the use of simulation to others for education on human trafficking.

Audience: This simulation is intended for 4th year medical students.

Introduction: Headache is the fifth most common chief complaint in the emergency room, and the vast majority are ultimately diagnosed as benign primary headaches.1,2 However, subarachnoid hemorrhage (SAH) is one of several critical diagnoses which can present as a headache. With a case fatality rate of up to 66.7% in some instances, SAH is considered a “can’t miss” diagnosis.3

Subarachnoid hemorrhage is classically associated with a thunderclap headache, one definition of which is a headache that reaches maximal intensity within one minute or less and reaches a seven out of ten in severity.1 Unfortunately, a thunderclap headache is not as sensitive nor specific for SAH as is often taught. In one study, only 50% of patients with an aneurysmal subarachnoid hemorrhage presented with a thunderclap headache and an additional 19% of SAH headache came on more gradually over the course of five minutes.4 A second study found that only 66% of SAH patients reported a thunderclap headache.2 Thunderclap headaches can also be associated with other intercranial pathology including intracerebral hemorrhage, cerebral venous thrombosis, cervical artery dissection, posterior reversible encephalopathy syndrome, meningitis, and temporal arteritis among others.1,2 In a large observational study, SAH accounted for 32% of the serious pathology cases identified in patients with a thunderclap headache. Even among the thunderclap headache cohort, however, 88% of patients ultimately had a benign diagnosis (compared to 93% of patients who did not report a thunderclap headache).2

Additional signs and symptoms of SAH include seizures in 6-9% of patients, vomiting, neck pain and stiffness, visual disturbances, loss of consciousness, and focal cranial nerve or supratentorial deficits.1,5 A non- contrasted computer tomography (CT) of the head within six hours of headache onset can have a sensitivity of98.7to100%;however,thesensitivitydecreasedto86%atthe24-48hourmark.1,6 Ameta-analysisfound a pooled six hour sensitivity of 1.0 and asserts that a head CT interpreted as negative by an attending

radiologist effectively rules out SAH in neurologically intact patients with a defined onset of a thunderclap headache.6 Some guidelines in the United States still recommend shared decision making with the patient to choose between a Lumbar Puncture (LP), Computer Tomography Angiogram (CTA), or no further testing to rule out SAH in the case of a negative head CT.2 The more time that has elapsed between onset and CT imaging, the stronger the recommendation to pursue further testing. A negative head CT followed by a negative LP approaches 100% sensitivity for ruling out SAH, and a negative head CT with a negative CTA has a 99.4% probability of ruling out SAH.1,3 Thus it is an important learning point that if a headache has been ongoing for more than six hours and there is a high pre-test probability for an SAH, a negative head CT is not sufficient to rule out the diagnosis, and a secondary test should be ordered.

Status epilepticus is defined as five minutes of continuous seizure activity or repeated seizures without return to baseline between seizures.7 The immediate priorities for a seizing patient include providing supplemental oxygen, considering intubation if patient is unable to protect airway, obtaining IV access if not previously established, and checking glucose.7 The main priority for a patient in status epilepticus is to stop the seizure with seizure abortive medications, typically benzodiazepines, and treat life-threatening causes of status epilepticus.7 This simulation will enable learners to diagnose SAH that is not the classical “worst headache of my life” and manage an actively seizing patient.

Educational Objectives: At the conclusion of the simulation leaners will be able to:

b. Provide supplemental oxygen

c. Administer an IV or IM benzodiazepine to treat the seizure

5. Utilize the I-PASS framework to communicate with the inpatient team during the transition of care

Educational Methods: This summative simulation was designed to assess competence in two of the core Entrustable Professional Activities (EPAs), as defined by the Association of American Medical Colleges (AAMC). These include EPA 8 (Give or Receive a Patient Handover to Transition Care Responsibility) and EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). It was performed with 4th year medical students at the conclusion of their required month-long emergency medicine (EM) clerkship. This scenario joined eight other scenarios in our pool of potential cases. These sessions are conducted using a high-fidelity manikin as the patient and a confederate/actor in the nursing role. The students complete the assessment in groups of three or four with each student acting as the team lead for one scenario. After each scenario concludes, there is a post-simulation debriefing session on the presentation, differential diagnosis, physical exam findings, and management of the target pathology. A Gather-Analyze-Summarize technique was used for the debriefing session.8

Research Methods: Facilitators provided informal feedback to the scenario developers after the case was introduced into the assessment rotation. Learners completed a standard evaluation issued by the College of Medicine for the entire session rather than for individual scenarios. These evaluations were reviewed for the first year of implementation of this new case. Over the year, 209 students completed the summative simulation exercise, and 84 of those students completed this simulation as part of the overall exercise.

Results: Overall, our facilitators felt the case fit well into our pool of simulation cases. They felt they were adequately able to assess the students’ ability to respond to a seizing patient and thought the difficulty level was appropriate for fourth year medical students. Students are asked to assess the simulation session as a whole using a standard evaluation form from the College of Medicine. The simulation assessment exercise as a whole was highly rated by the students, with 93% of students rating the overall quality of the session as Very Good or Excellent. Of the students who completed the SAH scenario, 96% rated the overall quality of the session as Very Good or Excellent. None of the comments specifically mention the SAH case.

Discussion: Our department has run formative simulations during the 4th year EM clerkship for over ten years. Our primary objective is to assess 4th year students’ competence in EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). This simulation case was written to replace another SAH case which was a more straightforward and typical presentation of a subarachnoid hemorrhage as “the worst headache of my life.” The previous case also did not require seizure management. The inclusion of the seizure management better allowed faculty to assess the students’ response to a patient’s acute decompensation, which is more in line with EPA 10, than simply making a critical diagnosis.

Our facilitators did notice that many groups initially work the patient up for meningitis but ultimately make the correct diagnosis with the lumbar puncture (LP) results. Because the students have correctly identified that the patient requires more extensive work up, and meningitis is certainly on the differential diagnoses, students are not penalized for following this line of clinical reasoning.

This simulation proved to be highly engaging for 4th year medical students, and students seemed to perform at a similar level as previous summative simulations. Overall, we felt this simulation successfully achieved the objectives of the simulation session as whole, and it was integrated into our 4th year EM clerkship simulation curriculum.

Audience: Intern and junior emergency medicine residents.

Introduction: Abdominal pain and vaginal bleeding in the first trimester of pregnancy are common presentations to the emergency department (ED).1 Formal transvaginal ultrasound (TVUS) is considered the test of choice for evaluation of first trimester pregnancy due to its high sensitivity and specificity for identifying intrauterine and ectopic pregnancies.1 Additionally, TVUS can evaluate for various uterine and ovarian pathology as well as identify other non-gynecologic conditions and is within the scope of practice for the emergency physician.2 Given the emergent and time sensitive nature of certain obstetric and gynecologic conditions, formal transvaginal ultrasound imaging may not be feasible. A rapid assessment with transvaginal point-of-care ultrasound (TVPOCUS) can be utilized by emergency medicine physicians (EMP) to confirm intrauterine pregnancies (IUP) and identify any associated complications. There are multiple advantages to TVPOCUS including reduced cost and length of stay, patient satisfaction, and improved resource utilization.1,3 Additionally, multiple studies demonstrate that EMPs can learn this skill and perform TVPOCUS accurately and safely.1,3 Developing the skills and comfort with TVPOCUS in a simulation setting during residency is beneficial and can have important implications in future practice.

Educational Objectives: By the end of the session, learners should be able to 1) recognize the clinical indications for transvaginal ultrasound in the ED, 2) practice the insertion, orientation, and sweeping motions used to perform a TVPOCUS study, 3) interpret transvaginal ultrasound images showing an IUP or alternative pathologies, and 4) understand proper barrier, disinfection, and storage techniques for endocavitary probes.

Educational Methods: This session included three high-fidelity simulation cases that allowed participants to utilize TVPOCUS in a safe and conducive environment. There was a total of 32 emergency medicine (EM) residents who participated. The simulation sessions were divided into two separate rooms and included four learners for each session that actively managed the patient, for a total of 12 active participants. The 20 remaining residents were observers. Participants learned evidence-based indications, performance, and interpretation of transvaginal ultrasound. Three cases were reviewed and included IUP, ruptured ectopic pregnancy with hemorrhagic shock, and appendicitis in pregnancy. The cases were followed by a debriefing session and discussion regarding the evidence behind bedside transvaginal ultrasound, its incorporation into EM workflow, and practice-based learning.

Research Methods: The educational content and efficacy were evaluated by oral feedback in a debriefing session after the workshop. Additionally, pre-simulation and post-simulation surveys were sent to participants to assess prior ultrasound experience and confidence on the indications, performance, and interpretation of transvaginal ultrasound. Responses were collected using a Likert scale of 1 to 5, with 1 being “not at all confident” and 5 being “very confident.”

Results: Ten learners responded to the survey consisting of EM residents in a three-year EM residency program. Prior to the workshop, the median reported confidence level across all questions was “1- not at all confident” for the PGY-1 class, and “3-neutral” for the PGY-2 and PGY-3 classes. Following the workshop, all median scores across all classes were “4-confident,” demonstrating an increase in confidence scoring across all measurements and participants. Incorporating transvaginal ultrasound into clinical workflow demonstrated the largest increase in confidence score (median 1.5 to 4), followed by insertion/orientation of the endocavitary probe (median 2.5 to 5).

Discussion: This high-fidelity simulation familiarized learners with transvaginal ultrasound and how it can be appropriately utilized for a variety of high-yield clinical scenarios that present regularly to the ED. Given the variation in ultrasound training among residency programs, and the lack of specific simulation content addressing this modality, it is important to implement scenarios that improve learner comfort with TVPOCUS. Overall, this workshop resulted in an increase in confidence scores of participants in the indication, performance, and interpretation of TVPOCUS in the ED.

This case report highlights an uncommon sequelae of chest wall trauma that should be evaluated for patients presenting with similar history and symptoms. A 60-year-old man presented to the emergency department (ED) with swelling, fever, and chest wall pain two days after an assault with blunt chest wall trauma. On exam, there was a suspected chest wall abscess, verified on computed tomography (CT) with associated displaced midsternal fracture. This patient was admitted for abscess incision and drainage. While uncommon, chest wall abscess formation is an important condition that should be considered as a differential diagnosis in any patient presenting with chest wall pain post blunt trauma. With few reported similar presentations in the literature, this case is an important addition in a likely underreported phenomenon that requires prompt evaluation and treatment.

Subtalar dislocations of the talonavicular and talocalcaneal joints are rare, accounting for approximately one percent of all dislocations.1 These dislocations are typically the result of a high energy mechanism and present a challenge during reduction attempts. We present the case of a male in his early 20’s who presented to the emergency department after a motorcycle accident with right foot and ankle pain and obvious deformity. Emergent X-ray and immediate attempt at reduction are of utmost importance with these dislocations. After multiple failed attempts at reduction in the ED, this patient was taken to the operating room for an open reduction with podiatry. This case report reviews the pathophysiology and management of this rare injury including nerve blocks and reduction techniques.

The authors present a case of symptomatic dermatographia. Dermatographia is an inducible urticaria where the light pressure of scratching leaves a raised wheal in the pattern of the scratching. The presentation can be striking and is often very stressful for the patient; however, the etiology is benign and the key takeaway is to provide reassurance to the patient.