Electrical Storm/Refractory Ventricular Tachycardia.

Audience: This simulation case was created for emergency medicine (EM) residents at all levels of training. Background: Cardiac electrical storm (ES) is commonly defined as three or more episodes of sustained ventricular tachycardia, ventricular fibrillation, or three shocks from an implantable defibrillator within a 24 hour period.1 This can occur in up to 30-40% of patients with implantable defibrillators; however, it may also present in a wide variety of patients, including those with structural heart disease, myocardial infarction, electrolyte disturbances, and channelopathies.2,3 With each subsequent episode of ventricular arrhythmia, the arrhythmogenic potential of the heart may increase secondary to increased intracellular calcium dysregulation, myocardial injury, and increased endogenous release of catecholamines. The increased pain and catecholamine release from cardioversion/defibrillation and exogenous epinephrine during cardiac arrest further exacerbates ES.2 This carries a significant mortality risk of up to 12% in the first 48 hours.3This case involves a basic knowledge of the Advanced Cardiac Life Support (ACLS) for ventricular tachycardia, both with and without a pulse, and the application of Sgarbossa criteria in a patient with an ST elevation myocardial infarction (STEMI) which makes it ideal for the PGY-1. However, the case quickly becomes refractory to the basic management prescribed in ACLS, requiring trouble shooting and quick thinking about deeper pathophysiology, a skill that is crucial for all emergency medicine physicians. There are multiple ways to troubleshoot this case, making for a good variety of discussion and recent literature review on the complexities of a relatively common arrhythmia, ventricular tachycardia. Educational Objectives: By the end of this simulation, learners should be able to: 1) recognize unstable ventricular tachycardia and initiate ACLS protocol, 2) practice dynamic decision making by switching between various ACLS algorithms, 3) create a thoughtful approach for further management of refractory ventricular tachycardia, 4) interpret electrocardiogram (ECG) with ST-segment elevation (STE) and left bundle branch block (LBBB), 5) appropriately disposition the patient and provide care after return of spontaneous circulation (ROSC), 6) navigate a difficult conversation with the patient's husband when she reveals that the patient's wishes were to not be resuscitated. Educational Methods: This simulation was performed using high-fidelity simulation followed by an immediate debriefing with nine learners who directly participated in the SIM and twenty-three residents, who were online observers via Zoom. This case was done during our conference day, and there were a total of approximately forty total learners comprised of medical students, PGY-1, PGY-2 and PGY-3 residents. There were several medical students who also observed via Zoom but were not surveyed, and the survey was sent to 32 learners. The case was run three separate times with each session consisting of three-four learners at the same level of training, with other learners in the same level of training observing via Zoom™ video platform. Since we can only have a team of three-four learners participate per group during simulation, the rest of the learners were observing the case and the debrief. There was one simulation instructor and one technician. Research Methods: We sent an online survey to all the participants and the observers after the debrief via surveymonkey.com. The survey collected responses to the following statements: (1) the case was believable, (2) the case had right amount of complexity, (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. Likert scale was used to collect the responses. Results: A total of thirteen participants responded to the survey. One hundred percent of them either strongly agreed or agreed that the case was believable and that it helped in improving medical knowledge and patient care. Fifty-four percent strongly agreed, 38 percent agreed, and eight percent were neutral about the case having the right amount of complexity. Thirty one percent strongly agreed, 61 percent agreed, and eight percent were neutral about the case giving them real-life experience. All of them agreed that the debriefing session helped them improve their knowledge. Discussion: The high-fidelity simulation case was helpful with educating learners with ventricular tachycardia and fibrillation. Learners learned how to switch between various ACLS algorithms and how to manage a patient with refractory ventricular fibrillation. Learners enforced their knowledge in how to communicate with patient's family members when the patient does not want resuscitation. Topics: Stable ventricular tachycardia, unstable ventricular tachycardia, refractory ventricular tachycardia, electrical storm, STEMI equivalents, medical simulation.

Acute Exacerbation of COPD.

Audience: This case is targeted to emergency medicine residents of all levels. Introduction: Shortness of breath (SOB) is one of the top ten most common chief complaints seen in the Emergency Department, accounting for close to 10% of presenting complaints.1 An acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a frequent culprit, accounting for roughly 15.4 million visits and 730,000 hospitalizations per year.2 The diagnosis of treatment of mild to moderate AECOPD can be relatively uncomplicated; however, multiple factors can increase the complexity of management and pose additional challenges that the emergency physician (EP) must be prepared for. Severe AECOPD can necessitate the need for both Non-invasive positive pressure ventilator (NIPPV) such as bi-level positive airway pressure (BiPAP) as well as emergent intubation. Furthermore, managing the ventilator settings in patients with an AECOPD is far from routine, requiring an intricate understanding of pulmonary physiology.3. Educational Objectives: By the end of this simulation, learners will be able to (1) assess for causes of severe shortness of breath, (2) manage severe COPD exacerbation by administering appropriate medications, (3) identify worsening clinical status and initiate NIPPV, (4) assess the causes of hypoxia after establishing endotracheal intubation and, (5) identify indication for needle decompression and perform chest tube thoracostomy. Educational Methods: This simulation was conducted with a high-fidelity mannequin with a separate low fidelity chest tube mannequin that allowed for hands-on practice placing a chest tube. A total of 16 PGY-1 residents participated in the simulated patient encounter. Research Methods: Following the simulation and debrief session, all residents were sent a Likert scale survey via surveymonkey.com to assess the educational quality of the simulation. The survey contained the following questions; 1) Overall, this simulation was realistic and could represent a patient presentation in the Emergency Department, 2) Overall, the case contained complexity that challenged me as a learner, 3) This case helped to expand my medical knowledge, 4) I feel more confident in diagnosing and treating AECOPD, 5) I feel more confident in recognizing the indications for NIPPV and intubation, 6) This simulation offered an opportunity to improve my procedural skills, 7) I feel more confident in setting up the ventilator, 8) I feel more confident in addressing ventilator alarms. Results: Following the simulation and debrief session, all the participants (n=16), were provided a survey to assess the educational quality of the simulation. There were a total of 12 respondents and a hundred percent of them agreed or strongly agreed that the case contained complexity that challenged them. All of the respondents agreed that the simulation case was realistic and that the case helped expand their medical knowledge. Furthermore, all the learners agreed or strongly agreed that the case helped them in improving their procedural skills. Discussion: This case combines a mixture of high fidelity and medium fidelity components to encompass both clinical knowledge and procedural skills. This case is effective in expanding beyond the basic approach to managing an AECOPD patient and forces learners to address clinical deterioration, escalate airway interventions, manage ventilator settings, and address ventilator alarms, including placement of a chest tube. Residents commented that this case was very realistic and particularly challenging because it highlighted gaps in their clinical knowledge and procedural skills. Residents were most challenged by identifying when to escalate care as well as how to manage ventilator settings in AECOPD patients. Topics: Acute exacerbation COPD, intubation, positive pressure ventilation, ventilator alarms, chest tube thoracostomy.

Alcohol Withdrawal with Delirium Tremens.

Audience: Emergency medicine (EM) residents (1st year and 2nd year levels), 4th year medical students and advanced practice providers. Introduction: Alcohol use has played a major role in causing significant morbidity and mortality for patients. In 2016, it was the 7th leading risk factor for deaths and disability-adjusted life years globally.1 Among heavy alcohol users admitted for hospital management, the incidence of alcohol withdrawal syndrome is estimated to be 1.9 to 6.7%.1 Alcohol withdrawal (AW) in the ED has been associated with increased use of critical care resources, and frequent ED visits for alcohol-related presentations have been associated with mortality rates that are about 1-4% when withdrawal progresses to delirium tremens (DTs).1 Patients with alcohol withdrawal can present in many different ways to the ED including anxiety, tachycardia, delirium tremens (DTs), seizures and severe autonomic dysfunction leading to severe sickness and death.2 Therefore, it is extremely important for an EM physician to recognize the signs of AW in patients and to manage the critically ill patients. In addition, Clinical Institute Withdrawal Assessment (CIWA) of alcohol was developed to assess severity of alcohol withdrawal in 1989.3 EM physicians should utilize CIWA to help determine the severity of AW. Educational Objectives: By the end of the session, learner will be able to 1) discuss the causes of altered mental status, 2) utilize CIWA scoring system to quantify AW severity, 3) formulate appropriate treatment plan for AW by treating with benzodiazepine and escalating treatment appropriately, 4) treat electrolyte abnormalities by giving appropriate medications for hypokalemia and hypomagnesemia, and 5) discuss clinical progression and timing to AW. Educational Methods: This session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. The session was run during first year EM resident intern orientation, and it was run during two consecutive years. There was a total of 32 EM residents who participated. There was a total of 16 residents who actively managed the patient while the other 16 were observers. Each session had four learners and was run twice in two separate rooms. There was one simulation instructor running the session and one simulation technician who acted as a nurse. Research Methods: After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the participants. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right the amount of complexity (based on their Gestalt), (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. The responses were collected using a Likert scale of 1 to 5 with 1 being "Strongly disagree" and 5 being "Strongly agree." Results: There was a total of 15 respondents from both years. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning, in improving medical knowledge and in patient care. All of them found the post-session debrief to be very helpful. Two of them felt neutral about the case being realistic. The median response for questions 1, 3 and 5 is 5. The median response for questions 2 and 4 was 4. The range of responses for questions 1, 2, 3 and 5 was 4-5 while the range for question 4 was 3-5. Discussion: This high-fidelity simulation was a cost-effective and realistic way of educating learners on how to manage AW with DTs. Learners are forced to start with a broad differential for the patient who presents with AMS. As they recognize the cause of mental status, the patient quickly decompensates into developing severe agitation and autonomic dysfunction requiring learners to manage the patient and establish an airway. Learners found the case to be beneficial in learning the management of AW. Topics: Alcohol withdrawal, delirium tremens, agitation, altered mental status.

Torsade de Pointes Due to Hypokalemia and Hypomagnesemia.

Audience: This scenario was developed to educate emergency medicine (EM) interns but can be used to educate medical students and junior residents. Introduction: Torsade de Pointes (TdP) is a rare but potentially fatal arrythmia if not quickly diagnosed and properly treated. TdP is defined as a polymorphic ventricular tachycardia (VT) characterized by an oscillatory change in amplitude around an isoelectric line that is associated with a QTc prolongation on the electrocardiogram (ECG).1 It has been well described to predispose to ventricular fibrillation and arrhythmic death. QTc prolongation can be congenital or acquired. Between 1 in 2000 to 20,000 have the genetic mutation for QTc prolongation.1 Acquired QTc is most commonly drug related leading to electrolyte abnormalities. 2 Around 28% of cases of TdP are associated with hypokalemia and hypomagnesemia.2 Several European centers estimate 0.8 to 1.2 per million people per year are drug induced.1 Patients with TdP most commonly presents with syncope, palpitations, and dizziness.2 While 50% are asymptomatic, up to 10% of patients will present in cardiac arrest.1 It is imperative for EM physicians to be able to recognize TdP as it can quickly decompensate into a ventricular fibrillation and sudden death. These patients require management of electrolyte abnormalities, ventricular dysrhythmias, and cardiac death.2 This simulation case will demonstrate treatment strategies for TdP with electrolyte repletion, antiarrhythmics, and defibrillation. Educational Objectives: By the end of this simulation session, learners will be able to: 1) formulate appropriate work-up for altered mental status (AMS) 2) recognize hypokalemia and associated findings on ECG 3) address hypomagnesemia in a setting to hypokalemia 4) manage pulseless VT by following advanced cardiac life support (ACLS) 5) recognize and address TdP 6) provide care after return of spontaneous circulation (ROSC) 7) consult intensivist and admit to intensive care unit (ICU). Educational Methods: This session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. Each session had three EM first-year residents and six observers. There was one simulation instructor running the session and one simulation technician who acted as a nurse. Research Methods: After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the participants. The survey collected responses to the following questions: (1) was the case believable? (2) did the case have the right amount of complexity? (3) did the case help improve medical knowledge and patient care? (4) did the simulation environment gave a real-life experience? (5) did the debriefing session after simulation help improve knowledge? A Likert scale was used to collect the responses. Results: This case was performed once a year for 2 years in a row. There was a total of 19 respondents from both years. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning and in improving medical knowledge and patient care. All of them found the post-session debrief to be very helpful. Two of them felt neutral about the case being realistic. Discussion: This high-fidelity simulation was a realistic way of educating learners on how to manage hypokalemia and hypomagnesemia leading to TdP. Cost-effectiveness varies depending on what is available at individual simulation laboratories. Learners are forced to start with a broad differential for the patient who presents with AMS. As they manage the case, the patient quickly decompensates into a fatal arrhythmia due to electrolyte abnormalities. Learners enforced their knowledge on leading ACLS, intubation skills, and treating TdP with electrical conversion and electrolyte repletion. Topics: Hypokalemia, hypomagnesemia, torsades de pointes, altered mental status, medical simulation.

Massive Upper Gastrointestinal Bleeding.

Audience: This case is targeted to emergency medicine residents of all levels. Introduction: Upper gastrointestinal bleeding (UGIB) is a common chief complaint encountered in the emergency department, resulting in over 500,000 hospitalizations and 20,000 deaths annually in the United States.1 The diagnosis and management of UGIB in stable patients is typically fairly straightforward. However, there are a number of circumstances where the treatment of UGIB is much more challenging, and emergency medicine (EM) physicians should be familiar with, and have experience managing, these difficult presentations. Massive UGIB can necessitate the need for management of a difficult airway in the setting of airway contamination, as well as placement of a gastroesophageal balloon tamponade device. The appropriate use and indications for performing this high-risk/low-frequency procedure requires dedicated practice. Furthermore, the management of gastrointestinal hemorrhage in a patient with a religious objection to the administration of blood products, including Jehovah's Witnesses, can be especially challenging and requires knowledge of alternative therapies to support blood pressure, oxygen carrying capacity, and decrease coagulopathy.2,3. Educational Objectives: By the end of this simulation, learners will be able to: 1) manage a hypotensive patient with syncope and hematemesis, 2) pharmacologically manage an acute UGIB addressing the various causes, 3) recognize worsening clinical status and intervene by performing difficult airway management, 4) place a gastroesophageal balloon tamponade device. Educational Methods: This simulation was conducted with a high-fidelity mannequin with a separate medium-fidelity intubating mannequin that was modified to allow rapid filling of the oropharynx with simulated blood. Due to the COVID-19 pandemic, a total of six EM residents in various levels of training participated in the simulated patient encounter while the rest of the learners watched the simulation and participated in the debrief via video conference. Research Methods: Following the simulation and debrief session, all the residents, including those who participated in-person and via video conference, were sent a survey via surveymonkey.com to assess the educational quality of the simulation. Results: Overall residents expressed positive feedback on the scenario, noting that the case was realistic, appropriately complex, and improved their medical knowledge and procedural skills. Discussion: This case has a mixture of high-fidelity and medium-fidelity components which can be easily reproduced. The case was extremely useful in teaching EM residents of all levels not only how to manage large volume UGIB in a patient who is also a Jehovah's Witness, but also how to manage the airway and place a gastroesophageal balloon tamponade device. The case starts with a patient presenting with syncope and as the case unfolds, the patient's clinical status deteriorates, requiring learners to resuscitate, intubate, and obtain a gastroesophageal balloon tamponade.Residents commented that managing this case of an UGIB was extremely challenging because it exposed and filled important gaps in both their knowledge and procedural skills. Residents struggled most with identifying alternative therapies to blood products in patients with religious objections, and the step-by-step process of placing a Blakemore tube. Topics: Upper gastrointestinal bleed, hemorrhagic shock, Jehovah's Witness, difficult airway.

Virtual Town Hall Meetings to Convey Emergency Medicine Residency Program Information to Students.

BACKGROUND: Applying to emergency medicine (EM) residency programs as a medical student is challenging and complicated in a normal year, but the 2020/2021 application cycle was further complicated by the COVID-19 pandemic. Due to the decrease of in-person opportunities for students to connect with residency programs, virtual "town-hall" meetings were developed. In this study our primary objective was to determine whether attendance at a virtual residency program information session improved the perceived knowledge of curriculum information and program exposure to medical students applying to an EM residency. METHODS: Four study sites hosted a total of 12 virtual events consisting of residents, faculty, or both. Standardized pre-event/post-event surveys were conducted to capture medical student perceptions before/after each of the virtual sessions. Apart from measuring the improvement in students' perceived knowledge of a program by gauging their responses to each question, we used a 10-question composite score to compare pre- vs post-event improvement among the participants. RESULTS: The pre-event survey was completed by 195 attendees, and the post-event survey was completed by 123 attendees. The median and mean composite score to this 10-question survey improved from 32.19 to 45, and 31.45 to 44.2, respectively, in the pre- to post-event survey. CONCLUSION: This study showed improvement of medical students' perceived knowledge of residency programs (reflected as increased agreement from pre- to post-event survey). The data demonstrates through question responses that students not only obtained information about the programs but also were able to gain exposure to the culture and "feel" of a program. In a non-traditional application season in which students are unable to pursue their interest in a program through audition rotations, virtual town hall events, along with other asynchronous events, may be a reasonable approach to increasing medical student understanding and awareness of a program and its culture.

Meningococcal Meningitis with Waterhouse-Friderichsen Syndrome.

Audience: This scenario was developed to educate junior and senior emergency medicine (EM) residents. It can also be cut short to be used for 4th year EM bound medical students. Introduction: Meningococcal meningitis is a devastating disease that can cause severe neurologic sequelae if not diagnosed early and treated appropriately. In 2017, Centers for Disease Control reports a rate of 350 cases (0.11 cases per 100,000) which makes it an extremely rare disease. The highest reported rate is under the age of 1 (0.69 in 100,000) with second peak in adolescents and young adults between the ages of 16 and 23 (0.29 in 100,000) and third peak in patients above the age of 80 (0.49 in 100,000).1 The presentation for bacterial meningitis includes neck stiffness, fever, vomiting, photophobia, positive Kernig and Brudzinski's sign, and lethargy. In addition, 80% patients with meningococcal meningitis have rash during some stage of their disease.2 A feared and rare complication of severe meningococcal disease is Waterhouse-Friderichsen Syndrome (WFS) which carries a high mortality rate of 20%. Therefore, early diagnosis and rapid management of meningococcal disease is highly imperative.3 This simulation case was written to demonstrate the presentation of meningococcal meningitis and to discuss the management of WFS. Educational Objectives: By the end of this simulation session, learners will be able to: (1) manage a patient with altered mental status (AMS) with fever while maintaining a broad differential diagnosis, (2) recognize the risk factors for meningococcal meningitis, (3) manage a patient with worsening shock and perform appropriate resuscitation, (4) develop a differential diagnosis for thrombocytopenia and elevated international normalized ratio (INR) in an altered febrile hypotensive patient with rash, (5) manage the bleeding complications from WFS, (6) discuss the complications of meningococcal meningitis including WFS, and (7) review when meningitis prophylaxis is given. Educational Methods: This session was conducted using high-fidelity simulation. It was immediately followed by an in-depth debriefing session. The session was conducted on a total of 9 EM residents from various levels of training who actively participated during the case and 25 residents who were observers. There was 1 simulation instructor running the session and 1 simulation technician who acted as a nurse. Research Methods: After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the learners. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right amount of complexity, (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. A ten-item Likert scale was used to collect the responses. Results: Ten learners responded to the survey. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning and improving patient care. They also agreed that it helped in improving medical knowledge. The post-session debrief was found to be very helpful by all the learners.. Discussion: This high-fidelity simulation case was not only cost-effective but also was very helpful in teaching EM residents how to manage a patient with meningococcal meningitis and WFS. The case was started with the patient presenting with altered mental status and fever, and as the case unfolded, mental status and shock worsened allowing the learners to intubate and resuscitate. Overall, learners also found the discussion of prophylaxis valuable. Topics: Meningitis, altered mental status, medical simulation, infectious disease, neurology, septic shock, Waterhouse-Friderichsen Syndrome, hematology.

Hemoptysis Due to Diffuse Alveolar Hemorrhage.

Audience: This scenario was developed to educate junior and senior emergency medicine (EM) residents. Introduction: EM Model of Practice recommends that the residents are able to manage patients in a critical condition from massive hemoptysis. Mild to moderate hemoptysis can be self-limiting and often can be managed with conservative measures; however, massive hemoptysis is a life-threatening emergency that needs to be managed promptly. Mortality from massive hemoptysis is about 13%-18%.1 There are several causes for hemoptysis ranging from pulmonary to vascular causes. Diffuse alveolar hemorrhage (DAH) causes hemoptysis only 0.2% which makes it a very rare but devastating disease.2 Hemoptysis from DAH can present a significant challenge to an EM physician since it can present in various ways including chest pain, shortness of breath or hemoptysis. Up to 40% of the patients can present without hemoptysis which makes it a diagnostic dilemma.3 Patients presenting with massive hemoptysis from DAH require management for hypovolemic shock, hypoxic respiratory arrest and potential cardiac arrest. The physicians also need to perform adequate ventilator management to help with alveolar recruitment. This simulation case can help discuss some of the nuances of the management of hemoptysis and DAH. Objectives: By the end of this simulation session, learners will be able to: (1) recognize worsening respiratory status of a patient with hemoptysis and intervene appropriately, (2) manage a patient with severe hemoptysis and perform appropriate ventilator management, (3) manage sinus tachycardia with QT prolongation on the ECG caused by cocaine and hypomagnesemia, (4) address various etiologies of hemoptysis, (5) discuss the causes of massive hemoptysis and management options, and (6) review ventilation strategies in an intubated hypoxic patient. Educational Methods: This session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. Each session had 3 EM residents from various levels of training on the team and 7 observers. There was 1 simulation instructor running the session and 1 simulation technician who acted as a nurse. Research Methods: After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the participants. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right amount of complexity, (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. A Likert scale was used to collect the responses. Results: Seven learners responded to the survey. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning and improving patient care. They also agreed that it helped in improving medical knowledge. The post-session debrief was found to be very helpful by all the learners. Discussion: High-fidelity simulation was a cost-effective yet realistic way to manage severe hemoptysis, PEA (pulseless electrical activity), and persistent hypoxia in patients with diffuse alveolar hemorrhage. Starting the case with severe hypoxia that quickly progresses to PEA helps the learner to manage the patient quickly and effectively. Overall, learners enjoyed managing the patient, followed by discussing the various management strategies. Topics: Hemoptysis, diffuse alveolar hemorrhage, medical simulation, respiratory.

Necrotizing Fasciitis and Mediastinitis after Wisdom Tooth Extraction: A Case Report.

Necrotizing soft tissue infections with mediastinal extension are exceedingly rare. This submission provides dynamic and static visual stimuli (CT images) and a case report describing the history of present illness, initial ED presentation and inpatient course of a 33-year-old man who developed facial necrotizing fasciitis complicated by mediastinitis secondary to odontogenic infection following wisdom tooth extraction. Discussion of the key features of this rare presentation, the diagnostic and therapeutic approaches to making the diagnosis (including CT), and the role of the Emergency Physician, are highlighted. Topics: Necrotizing fasciitis, necrotizing mediastinitis, odontogenic infection, CT scan.

Extracorporeal Membrane Oxygenation (ECMO) for Refractory Cardiac Arrest.

Audience: Our target audience includes emergency medicine residents/physicians. Introduction: Treating cardiac arrest is a common theme during simulated emergency medicine training; however, less time is focused on treating refractory cases of cardiac arrest. There are varying definitions of refractory cardiac arrest, but it is most commonly defined as the inability to obtain return of spontaneous circulation (ROSC) after 10-30 minutes of appropriate cardiopulmonary resuscitation (CPR).1,2 More specifically, refractory ventricular fibrillation (VF) is defined as VF persisting despite 3 shocks, or the combination of 3 unsuccessful shocks plus amiodarone.1,3 Extracorporeal Membrane Oxygenation (ECMO) is becoming an increasingly utilized tool in the emergency department for severe cases of both pulmonary and cardiovascular pathology, and has been shown to be successful in cases of refractory cardiac arrest. Using ECMO in this scenario is known as Extracorporeal Cardiopulmonary Resuscitation (ECPR), referring to the emergent implementation of veno-arterial (VA) ECMO, and data have shown significantly improved neurologically-intact survival compared to routine CPR.3-7. Educational Objectives: Our objectives go beyond the basics of advanced cardiac life support (ACLS), forcing the learner to think about alternative treatments for refractory cardiac arrest. By the end of this session, the learner should be able to:Recognize refractory cardiac arrest and realize when advanced management is required beyond the basics of ACLSRecite the indications/contraindications to ECMODifferentiate the physiology and clinical requirements between using venous-venous (VV) ECMO for respiratory failure, and using VA ECMO for cardiovascular failureIdentify the anatomical cannulation sites for VV vs VA ECMOPerform the procedural skills to cannulate for both VV and VA ECMO. Educational Methods: This simulation is flexible. We used a high-fidelity mannequin with the "Endo-Circuit" to practice cannulating for ECMO, but the learning objectives can still be achieved with a lower-fidelity mannequin and cannulation device. The "Endo-Circuit" is a novel, low-cost vascular model developed by Dr Tomoyuki Endo from Sendai, Japan to practice ECMO cannulation.8,9 Endo-Circuit: Author's own imageAlternatively, a lower-fidelity model can be utilized if the Endo-Circuit is not available. We recommend using clear silicone tubing, which can be found at your local hardware store. This tubing should be at least 12mm in internal-diameter to accommodate the large ECMO catheters. We cut the tubing into 6-inch pieces so they could easily be swapped out for multiple participants to practice cannulating, all in a cost-effective manner. Red and blue tape was applied to differentiate the artery from the vein. Low-fidelity tubing: Author's own imageWe split our educational session into different stages. The first stage included the high-fidelity mannequin without the Endo-Circuit because we did not want to reveal our ultimate goal of starting the patient on ECMO by having the tubing overlying the mannequin. Neither standard ACLS methods nor advanced medications for refractory cardiac arrest lead to achieving ROSC in this scenario. Stage 1 ends when the learners suggest starting the patient on ECMO and call the appropriate consultants. After a short debrief on stage 1, we then transition to a 2nd mannequin that we had in the back of the room. This mannequin had the Endo-Circuit overlying, and everything was covered with a sheet, again so as not to reveal the goal of the simulation from the beginning. On this 2nd mannequin, we practiced cannulating for VA ECMO in the setting of cardiac arrest. Below are photos of the ECMO cannulation kit, the cannulated Endo-Circuit, as well as the cannulated lower-fidelity silicone tubing. ECMO Cannulation Kit: Author's own image Cannulated Endo-Circuit: Author's own image Cannulated low-fidelity silicone tubing: Author's own image. Research Methods: The learners filled out a post-simulation survey, which included questions specifically focused on the educational objectives (as mentioned above). We used a 1-5 Likert scale ranging from strongly disagree (1) to strongly agree (5) to quantify how the residents' understanding of the learning objectives improved after the simulation. This survey also included questions taken directly from the Debriefing Assessment for Simulation in Healthcare (DASH), which is a validated evaluation tool developed by the Center for Medical Simulation (CMS) for evaluating the efficacy of the educational content.10 The DASH scoring system involves a 7-point scale ranging from extremely ineffective/detrimental (1) to extremely effective/outstanding (7). Results: Thirty-one resident-learners participated in the simulation, and we received 22 survey responses. All of the learning objectives obtained a mean score >4 out of 5, with the exception of improving the learners' differential diagnosis for refractory cardiac arrest, which received a mean score of 3.86. The most successful of the learning objectives was improving the learners' procedural skills for ECMO cannulation, which received a mean score of 4.68. The DASH questions also reflected the success of the simulation, with 3 of the 6 questions receiving a mean score >6 out of 7, and the other 3 questions receiving a score >5. Discussion: According to this data, the learners found the simulation to be effective in expanding their knowledge base and improving procedural skills for starting critically-ill patients in refractory cardiac arrest on ECMO. Practicing the cannulation procedure on the Endo-Circuit was shown to be the most useful aspect of this simulation. The DASH survey questions further demonstrate that our methods created an engaging, structured environment to identify knowledge gaps and simultaneously fill them using hands-on, active learning. Topics: Extracorporeal membrane oxygenation, ECMO, cardiac arrest, refractory cardiac arrest, V fib, ventricular fibrillation, CPR, cardiopulmonary resuscitation, ECPR, extracorporeal cardiopulmonary resuscitation, ACLS, advanced cardiac life support, HOCM, hypertrophic obstructive cardiomyopathy, critical care, emergency medicine.