Jun 6, 2010 - Stations 3 and 4 involved a brief didactic lecture on relevant anatomy and tech- .... California (San Diego) School of Medicine,. Idaho State .... The high number of slides and the auto-advance forces a quick-paced deliv-.
2010 Innovations in Emergency Medicine Education (IEME) Each year, academic progress made in Innovations in Emergency Medicine Education (IEME) is presented as part of the Society for Academic Emergency Medicine Annual Meeting. Submission for presentation as IEME exhibits follows a different format, timeline, and judging process from the scientific abstracts. This year, we received 62 IEME submissions and accepted 20 for presentation. It is with pleasure that the editors of Academic Emergency Medicine publish in this issue the abstracts of the IEME exhibits that will be presented at the 2010 SAEM Annual Meeting in Phoenix, Arizona from June 3–6, 2010. These abstracts are published as they were received, with minimal editing, corrections, or clarifications; the authors are solely responsible for their content.
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Sight for Sore Eyes: A New and Simple Model for Teaching Lateral Canthotomy Melissa Nelson-Perron, Theodore J. Gaeta, Michael Cabezon New York Methodist Hospital
Retrobulbar hemorrhage is an ocular emergency whose prompt diagnosis and treatment are essential to prevent blindness. Orbital pressure can be relieved with a potentially sight-saving procedure, emergency lateral canthotomy. There are no commercially available simulation models that enable physicians to practice lateral canthotomy. We have developed a simply constructed partial task trainer that simulates a traumatized eye. The materials are listed as follows: 3x9’’ tray, two round tealight candleholders, white and red balloons, two elastic bands, four paper clips, one suture set, opaque material simulating skin. The two candleholders are placed in the tray forming orbits, and elastic bands are fixed with paperclips on either end to form canthal tendons. The red balloons are then cut and stretched over each candleholder to seal it. Two white balloons are very minimally inflated and, on them, iris and pupils are drawn for the ‘‘eyes’’. The eyes are then placed between the canthal tendons into 1-inch slits cut into the red balloons which hold them into place. The entire tray is covered by the opaque skin material except for the two eyes protruding through previously-cut slits. For a more realistic experience, the candleholders are filled with liquid simulating blood and the eyes are covered with lubricating jelly. Each model (~$6) can be used for up to four residents. This model was incorporated into a multimedia module and successfully executed in a 30 minute workshop. We will provide a detailed description of how to assemble the model and exhibit its utility in demonstrating and practicing the procedure (Crimp it, Snip it, Pluck it, and Cut it).
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Regions Emergency Medicine Residency (formerly St. Paul-Ramsey) Our residency program built a reusable fiberglass torso with cutouts for invasive truncal procedures. We purchased pig thoracic viscera and cow tracheas from a local butcher to replicate human organs. We replicated a human torso by molding a body cast of a mannequin with cast material (ScotchCast Plus, 3M Health Care, St. Paul, MN). We coated this cast with fiberglass matte and resin to waterproof the cast, then peeled off the fiberglass from the cast to leave a waterproof, reusable fiberglass torso. The torso was bivalved, allowing organs to be placed inside and easily accessible to demonstrate relevant anatomy. Residents performed thoracotomies by accessing the chest through a portion of the left ribcage built of ribs made from oven-hardening clay, pleura made from shelf liner, and intercostal muscles made from thin slices of meat purchased at a grocery store. The cricothyroidotomy training module was built by nestling a cow trachea in styrofoam wrapped in plastic wrap and placing it in the neck of the fiberglass torso, then covering it with simulated skin. An elliptical opening in the lower portion of the torso allowed access for diagnostic peritoneal lavage (DPL) and suprapubic bladder catheter placement. The abdominal wall was constructed from fabric. The bladder and abdominal cavity for DPL were simulated with beverage cups filled with simulated body fluid and covered with contact paper stretched over the tops. Total estimated materials cost for this trainer and 10 labs is under $1000.
Thoracotomy Training Without the Live Animal - Development of a Pre-fabricated Fiberglass Torso for Training EM Residents on Multiple Invasive Truncal Procedures Jessie G. Nelson, Rachel Ann Dahms, Felix K. Ankel
ISSN 1069-6563 PII ISSN 1069-6563583
ª 2010 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2010.00744.x
ACAD EMERG MED • May 2010, Vol. 17, No. 5, Suppl. 1 • www.aemj.org
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Cadaveric Models for Training Emergency Medicine Residents in Ultrasound-guided Peripheral Nerve Blocks Andrew Herring, Arun Nagdev, Andrea Durant, Daniel D. Price Alameda County Medical Center, Highland General Hospital
Increasingly, ultrasound-guided nerve blocks are an important part of emergency department (ED) pain management for procedures and acute traumatic injuries such as femoral fractures. As use of ultrasound-guided regional nerve blocks in the ED becomes more common, so, too, does the concern for adequate training to ensure safe and effective use of these techniques. We developed a cadaver laboratory for training emergency medicine (EM) residents in ultrasound-guided peripheral nerve blocks (PNBs). Cadaver models allow EM residents to practice in a risk-free learning environment without the time pressures of a busy ED. To our knowledge, no other EM residency curriculum has included training in ultrasound-guided PNBs using cadaveric models. Our ultrasoundguided nerve block training session involved four EM faculty and 12 first year EM resident trainees. Groups of three trainees rotated through the four didactic stations. Station 1 addressed the basic principles of ultrasound-guided regional anesthesia, including local anesthetic dosing and safety profiles, pathophysiology of nerve injury, management of compartment syndrome risk, patient monitoring, and common contraindications. Station 2 introduced the principles of ultrasound-guided needling technique, including strategies to maintain needle visualization and required hands-on probe and needle demonstration of trainee skill. Stations 3 and 4 involved a brief didactic lecture on relevant anatomy and technique for ultrasound-guided femoral and brachial plexus blocks, respectively. Resident trainees then practiced using ultrasound in real time to identify neuroanatomy and guide local anesthetic injections.
Figure for Abstract 4
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Sending Video Feedback To Learners Is Easy and Inexpensive Nicole Marie DeIorio, Ryan Palmer, Dawn Dillman, Tracy Bumsted, Scott Sallay, Scott Fields Oregon Health & Science University School of Medicine
Educational purpose: We saw a need for a method of providing more personal, engaging feedback in situations where faceto-face debriefing is not always possible. At our medical school, students are videotaped during case presentations. In the past, a checklist grading system was used, but evaluations from the students about the process showed they were unable to understand what they could improve upon without more concrete suggestions. Design: A publicly available video messaging website, www.eyejot.com, was used to e-mail video clips to students giving them feedback on their presentation skills. Methods used for implementation: Eyejot allows for the transmission of video clips as a simple e-mail message. While the course director has to create an account, recipients of the e-mail do not have to, and no software installation is required for either the sender or the viewer. A free account allows an unlimited number of messages of up to 60 seconds each; a Pro account ($3.95 per month) can be purchased to extend the video length up to 5 minutes. Results: Our instructors found the system easy to use, and unsolicited praise from students showed they appreciated the technology as well. Conclusion: Course directors and program directors should consider using this modality to provide more personal feedback in situations where real-time feedback is not possible, but the ability to better relay emotions, subtleties, and constructive advice is desired.
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2010 SAEM ANNUAL MEETING ABSTRACTS
Variation in Health Care: Recognition Is the First Step of Education-based Quality Improvement Category - Approaches To Evidence-based Learning Stewart W. Wright, Sunny M. Wang University of Cincinnati College of Medicine
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Introduction: Variation in health care increases cost and error and reduces quality. Between 44,000 and 98,000 Americans die from medical errors annually and only 55% of adults receive recommended care. Improvement in quality through reduced variation holds promise through the use of educational reminders, protocols, and evidence-based guidelines. However, changing existing physician behavior and educating physicians to adapt a new model is challenging. Implementation efforts typically show a change of behavior of 10% or less. To improve the readiness to change of physicians and facilitate their education, they must be shown that their practice patterns vary outside the norm. Methods: This IEME will be an interactive display that allows the participants to visualize the variation in practice patterns for several minor conditions across participants of the conference. Clinical vignettes of common complaints (e.g., cellulitis, dental pain) will be presented with treatment options available for each. The surveys will be completed and the results of all respondents displayed in real time at the booth. This visual reinforcement will allow participants to view their practice patterns compared to their peers for these complaints. To prevent preconceived notions of the ‘‘correct response’’ (bias), participants will not be allowed to view the aggregate results while taking the survey. At the conclusion of the exercise, participants will be given an evidence-based guideline adapted from current ISSA and Centers for Disease Control and Prevention recommendations. Impact: Recognition of variations in health care may enhance education by forcing introspective self-review of practice patterns.
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Deliberate Practice of Serial ECGs Taken From a Pediatric Emergency Department Neva M. Howard, Martin Pusic, Sarah Chambers, Anne Ferris Columbia University College of Physicians and Surgeons
Pediatric ECGs are different from adult ECGs due to different categories of diagnoses as well as age-dependent variations. Learning, teaching, and attaining proficiency in pediatric ECG reading is often haphazard in the pediatric emergency department (ED) setting since they are far less commonly performed than adult ECGs. Since proficiency in ECG reading requires practice on hundreds of examples, a typical emergency medicine (EM) trainee would be deficient with the relatively low numbers seen during a pediatric EM rotation. To address this problem we developed a web-based image bank of pediatric ECGs that will facilitate the deliberate practice of ECG interpretation. We gathered 250 consecutive ECGs seen in a tertiary care pediatric ED over the course of two months. The ECG cases were loaded into flash modules that allow for interactive reading of unknowns by the learner. The learner is presented with a brief history and the corresponding ECG. In each case, the learner must actively commit to an ECG being normal or abnormal prior to viewing expert feedback in the form of a report and mark-up of the ECG. A mySQL database keeps track of which cases to display as well as a cumulative estimate of the learner’s performance. Another important instructional strategy is that the image bank presents the same ratio of normals to abnormals as seen in actual pediatric practice. Using image banks, the medical learner can hone his or her skill with many repetitions of the authentic task, much like an athlete or musician. This allows the learner to efficiently acquire knowledge that is normally gained through years of practice. We envision using this approach for other visual tasks, such as x-ray interpretation or physical diagnosis.
Pandemic Flu Patient Surge Planning and Practice in a Virtual Environment Laura S Greci, Rameshsharma Ramloll, Samantha Hurst, Karen Garman, Jaishree Beedasy, Eric B Pieper, Ricky Huang, Helene Hoffman, Micha Cardenas, Michael Gates, Kristen Kho, Todd Porteous, Zia Agha VA San Diego Healthcare System, University of California (San Diego) School of Medicine, Idaho State University, University of California (San Diego) Family and Preventive Medicine, VA Long Beach Healthcare System, University of California (San Diego) CalIT2 and Visual Arts
Objectives: 1) Examine the use of a virtual learning environment for the delivery of pandemic flu patient surge functional drills for emergency department (ED) nurses and hospital incident command personnel, and 2) Explore the use of a multi-user virtual environment to enable a team-based approach to patient triage during a surge in health care utilization. Virtual environments can support an approach to learning that emphasizes student-centeredness and enables learning to be related to context and practice. In collaborative learning theory, the learner is seen as an active participant in the learning process, constructing knowledge through interaction with peers and instructors. Within the multi-user virtual environment, a user can interact by virtue of an avatar, a computerized character that represents the user. The avatar manipulates and interacts with objects in the virtual world. These virtual worlds are shared spaces where an entire organization of learners can simultaneously experience the same standardized yet evolving online world. These characteristics make virtual worlds more like the real world and less like the static, intermittent, stand-alone exercises and games used in traditional emergency preparedness training. We will present the results of our pilot studies to develop a curriculum for ED nurses and hospital incident command staff to deal with a large influx of patients. We will also present our curriculum and show how students learned to: 1) function in their job class in a virtual world; 2) obtain Healthcare Incident Command System (HICS) training; 3) practice Emergency Severity Index and START (simple triage and rapid transport) triage on simulated virtual patients; 4) perform several functional team exercises; and 5) visualize and evaluate their own performances during the functional drills. We will show video clips (machinimas) of the virtual lessons. We will also discuss our lessons learned including improved team communication, planning, team decision-making, and the ability to visually debrief. We hope that participants will come away with a new appreciation for how this immersive teaching method can support the delivery of disaster management education through all phases of the cycle (mitigation, preparedness, response, and recovery).
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Novel Simulation Curriculum in Wilderness Medicine Training Sanjey Gupta, John Lemery, Christine Zink, George Benedetto New York Hospital Medical Center of Queens/ Cornell University Medical College
Wilderness medicine is a multi-disciplinary field focused on the treatment of disease in the backcountry. Most medical student rotations focus on clinical lectures, improvised wilderness skills sessions (e.g., litter or flutter valve construction), and field moulaged standardized patient scenarios for education. Cornell Wilderness Medicine (CWM) has augmented its student curriculum with hospital-based high-fidelity manikin simulations and task training. The traditional, in situ, field curriculum has several limitations: (1) access to and transportation of supplies, actors, students, fac-
ACAD EMERG MED • May 2010, Vol. 17, No. 5, Suppl. 1 • www.aemj.org ulty to the wilderness, (2) video-recording ability for team training, and (3) ability to practice invasive procedures on actors. CWM has begun to practice scenarios in the hospital using the Laerdal SimMan. This transforms the simlab into an ‘‘austere’’ wilderness camp for the ‘‘in situ’’ scenarios. The manikins are programmed and moulaged for traditional wilderness medicine cases, e.g., hypothermia, anaphylaxis, etc. To continue instruction in improvisational medicine, students do not have access to hospital resources, only their ‘‘field’’ medical kit. To ensure similar experience for students, scenarios in the simlab and in the field are video-recorded and evaluated by faculty for similar student participation: (1) time to critical actions, (2) signs of student stress, and (3) team leadership and organization. Further, using moulaged actors limits practice for critical, invasive, life-saving procedures in the wilderness. CWM has introduced the use of the Simulab TraumaMan to practice backcountry, improvised procedures, e.g., cricothyroidotomy with a cut syringe, chest tube with hydration tubing, etc.
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Integrating Issues of Diversity and Health Care Disparities in an Emergency Medicine Resident Curriculum: A Novel Approach Sheryl L. Heron, Bisan Salhi, Nadria Gordon, Sally A Santen Emory University School of Medicine
As the US population continues to grow and include an increasing number of ethnic and racial groups, health care disparities persist and frequently go unrecognized. The Council of Emergency Medicine Residency Directors (CORD) recently reviewed the current state of ethnic and racial diversity in emergency medicine (EM) and recommends cultural competence curriculum development and the availability of institutional and national resources to improve and maintain diversity in EM training programs. In July 2009, Emory implemented a novel approach to embed the subject of diversity and disparities in health care throughout the resident curriculum. The Emory EM residency program follows the 18-month curriculum inclusive of EM topics (i.e., cardiovascular care). Rather than a stand-alone lecture on diversity and disparity in care, we designed a curriculum to include an introduction to diversity/disparities in EM, activities on community reflection, case studies in health care disparities, and integration of disease-specific disparities literature within applicable faculty-delivered resident lectures. Prior to the start of clinical responsibilities, Emory residents are taken on a visit of neighboring facilities to gain insight into the lives of patients seen. To date, eight didactic lectures have included objectives on diversity and/or disparate care in the population. We postulate that the integration of such topics into an alreadyexisting curriculum leads to greater exposure of the subject of diversity in EM and healthcare disparities. Potential outcomes could include improvement in patient satisfaction and quality of care.
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A Novel Application of 2-Dimensional Computer Simulation for Clinical Decision-making Spencer Adoff, Kevin King Penn State Hershey Medical Center
The focus of this educational project was the development and preliminary testing of a low-cost, two dimensional flat screen simulation to test decision-making, evaluate decision cascades in the clinical thinking process, and emphasize the effect of management choice on patient outcome. The answer choices have potential positive or deleterious effects to more realistically demonstrate the effect of real-world decisions. A urosepsis scenario was designed using Microsoft Power Point 2007 TM. A flow chart was used to detail the clinical decisions, critical action steps, and treatment options for the simulation. Critical action steps included in the decision pathway emphasized the importance of patient history, physical examination, assessment of ABCs, and complications of over-aggressive management and hasty decisions. A list of hyperlinked intervention choices was provided at each critical decision step. Correct answers were directly linked to the next step in the
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decision cascade. Incorrect answers had a deleterious effect on the patient’s clinical condition and were linked to a different treatment pathway. The three further treatment pathways for an incorrect answer were: correction and continuation, continuation with complication, and premature termination with return to the immediate prior critical action step. There were 20 participants in the simulation, divided into 4 groups of 5, with all levels of clinical experience represented in each group. Post-simulation comments included a desire for future use of this simulation design and that they benefited from working through a real patient case.
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A Simply Constructed, Economical, and Reusable Task Trainer for Simulating Intracompartmental Pressure Measurements Andrew Fischer Dean, Daniel Girzadas Jr., Steven Delis, Lamont G. Clay Advocate Christ Medical Center, University of Illinois College of Medicine at Chicago
Compartment syndrome is a threat to a patient’s life and limb. A true surgical emergency, it is an uncommon clinical diagnosis, often requiring the measurement of intracompartmental pressures. Performing these measurements using a handheld monometer (e.g., Stryker Needle) is a necessary skill for the emergency physician. Traditionally, emergency physicians learned such techniques in real time, at the beside, on patients with severe extremity injuries. Medical education is moving toward simulation for training and assessment of procedures such as intracompartmental measurement, because it allows learners to practice time-sensitive skills without risk to the patient or learner (1, 2). No commercially available simulation models enable physicians to practice intracompartmental measurement. We have developed an intracompartmental measurement task trainer that can be attached to the ‘‘injured’’ limb of the mannequin and requires the physician to properly set up and zero the Stryker needle, insert the needle into the suspected ‘‘compartment’’, and obtain an abnormally high reading on the monometer. Our model can be simply constructed using basic medical supplies in approximately one hour. Our model costs roughly $25.00. Materials needed for the construction of the model include a 100 ml bag of normal saline, a 10 ml syringe, an 18 gauge needle, a roll of silk tape, a bottle of betadine, and simulation mannequin skin. Once prepared, the model is usable for numerous measurements. When the model shows signs of wear, it can be easily remade by simply recycling the existing materials. 1. Ann Emerg Med. 2001, 37:745–770. 2. Acad Emerg Med. 2008, 15:1046–1057.
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BLAST: A Novel Presentation Format To Encourage Focused Rapid-Fire Knowledge Transmission Scott D Weingart, Phillip Andrus Mount Sinai School of Medicine
Over the past few years, the design field has undergone a revolution in slide design and presentation style. For the most part, these changes have not trickled down to medical presentations. Often, we attend lectures in which the presenter is reading verbatim for 60 minutes from dull, text-laden slides. In contrast are the short, focused presentations of the Pecha Kucha format. Created by two architects, this is a 20 slide presentation with automatic slide advance every 20 seconds. The high number of slides and the auto-advance forces a quick-paced delivery and graphic slide design. This format is now used across the world and has spawned derivatives such as Ignite. Two years ago, we created our own version, which we have named EM BLAST. The BLAST format consists of 8 minute presentations timed by a stopwatch. There is a minimum of 24 slides,
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2010 SAEM ANNUAL MEETING ABSTRACTS
with £ 8 written words per slide. This mandatory high number of slides achieves a similar effect to auto-advance, with less stress for the presenter. Three to five lectures work well as a BLAST competition. After they are completed, the audience votes on the winning presentation and prizes are awarded. We have used this format over the past two years at our annual New York Emergency Medicine Critical Care symposium. We use BLAST after the lunch break when audience energy levels are flagging. We feel that the rapid delivery and concise messages provide the best chance of knowledge transmission in our sleepy, adult learners. The audience feedback for this format has been uniformly outstanding. In conclusion, BLAST is a novel presentation format that has the potential to add to the quality and diversity of conferences and symposia.
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Resident Experience Mapping: A Novel Use of Graphical Analytic Tools and Electronic Medical Records for the Evaluation of Resident Clinical Experience John P. Marshall, Steven Horng Maimonides Medical Center
The widespread adoption of electronic medical records (EMRs) in emergency departments (EDs) has created new opportunities for the evaluation of emergency medicine residents. EMRs are now automatically capturing detailed data on the actual work being done by residents in the ED. However, these data can be difficult to access and are frequently in a format that is difficult to interpret. Advances in technology have created a new set of open source tools to extract and display information in a manner that is easily understood. We first created a 1-to-1 mapping between ICD-9 Codes and the EM Model of Clinical Practice (EMMCP). Database scripts were used to collect, aggregate, and process resident data. We then used a free, flash-based data visualization library to create interactive visual displays. The result was an interactive resident experience map displaying clinical experiences organized by categories of the EMMCP which can be trended over time and compared to those of their peers. These results were then hosted on a secure SharePoint intranet website. While residency programs can standardize the didactic curriculum for residents, the clinical experience can be highly variable, and without these tools, almost impossible to assess. By periodically reviewing the resident experience map, programs can identify deficiencies in areas of clinical experience and subsequently create data- driven educational interventions. These tools can similarly be used to assess individual resident procedural and critical care experience, as well as other clinical and administrative metrics. This interactive IEME display will demonstrate how commonly available tools can create new methods of resident assessment.
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APLS: A Novel Adaptation for Emergency Medicine Residency Training Margie Teng, Jessica E. Pierog, Sangeeta Chona, Bernard Dannenberg, N. Ewen Wang Stanford/Kaiser Emergency Medicine Residency
Goal: To provide multifaceted and interactive pediatric emergency medicine (PEM) training. Background: Historically our EM residency PEM education was a lecture series modeled on the adult curriculum. To enhance PEM education, we used the Advanced Pediatric Life Support (APLS) course as a foundation. APLS was developed by the American Academy of Pediatrics (AAP) in conjunction with the American College of Emergency Physicians. APLS goes beyond basic resuscitative care and is physician-oriented. The APLS toolkit offers a text and a CD ROM of lecture templates. Process: With AAP support, we adapted APLS into a program consisting of monthly lectures and bimonthly simulation sessions incorporating required APLS skills stations. Innovations include: 1)
two year modular structure designed for increased knowledge retention, 2) pediatric subspecialist speakers who are encouraged to supplement slides with their experience, 3) addition of simulation to integrate lectures and skills into patient management, and 4) online course administration, including attendance tracking and exams. Unanticipated enthusiasm after initiation resulted in overall increased conference attendance on APLS lecture days as well as faculty requests to participate. Costs of implementation include: 1) administrative support, 2) the APLS tool kit, 3) the APLS textbook for each participant, 4) simulation equipment, 5) physician teaching time, and 6) nurse participation. Anticipated Outcomes: Residents and faculty certified in APLS, and improvement of in-training exam scores and mock oral board scores after implementation. Conclusion: The APLS curriculum can be easily adapted to serve as a standard PEM curriculum for EM residency programs.
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Development of a Low-Cost Transvenous Pacemaker Placement Simulator for Resident Training Suzanne Dooley-Hash, Brian Russell Sharp University of Michigan
Transvenous pacemaker (TVP) placement is a potentially life-saving procedure that every emergency physician must be competent to perform. Traditional training methods rely on trainees’ chance clinical encounters with patients who require pacing. Because pacing is infrequently performed, actual individual trainee experience may vary and some may finish residency training with little or no clinical experience with TVP placement. Simulators have been developed for many emergency procedures, but there is no simulator commercially available for TVP placement. Using simple, inexpensive materials (
