Escape box and puzzle design as educational methods for engagement and satisfaction of medical student learners in emergency medicine: survey study.

BACKGROUND: Gamification in medical education has gained popularity over the past several years. We describe a virtual escape box in emergency medicine clerkship didactics to teach chest pain and abdominal pain and compare this instructional method to a traditional flipped classroom format. METHODS: A virtual escape box was designed at our institution and incorporated into the mandatory two-week emergency medicine clerkship. The game consisted of a PDF with four cases containing puzzles to unlock a final clue. Likert scale surveys were administered to assess participants' perceptions of the escape box format; of clerkship didactics as a whole; and of the clerkship overall. These responses were compared to the prior year's evaluations on flipped classroom didactics and clerkship. RESULTS: One hundred thirty-four learners participated in the escape box and completed the survey. Eighty-six percent strongly agreed with feeling more engaged with the escape box, 84% strongly agreed with learning something new, 81% strongly agreed with finding the escape box to be satisfying, 78% strongly agreed with being able to apply knowledge gained, and 74% strongly agreed with wanting more escape boxes incorporated into medical education. The escape box showed a higher average score (3.6 ± 0.63) compared to chest pain (3.5 ± 0.67) and abdominal pain (3.2 ± 0.77) flipped classroom sessions (p = 0.0491) for the category of "lecturer explaining content clearly and at the proper level of complexity." For the category of "lecturer provided effective instructional materials," the escape box showed higher scores (3.6 ± 0.63) compared to flipped classroom for chest pain (3.4 ± 0.77) and abdominal pain (3.1 ± 0.80) (p < 0.001). CONCLUSIONS: Escape boxes are adaptable to a virtual format and can teach abstract concepts such as teamwork and communication in addition to traditional lecture content. Ratings of didactics were higher for the escape box compared to the flipped classroom, while ratings of overall clerkship experience were not found to change significantly.

Ultrasound measurements of carotid intima-media thickness and plaque in HIV-infected patients on the Mediterranean diet.

AIM: To evaluate the influence of food habits, specifically adherence to the Mediterranean diet, on carotid intima-media thickness (CIMT) and the presence of plaques in HIV-infected patients taking antiretroviral therapy (ART) and non-HIV-infected participants and to determine if HIV infection contributes independently to subclinical atherosclerosis. METHODS: We conducted a cross-sectional study of 110 HIV-infected patients on ART and 131 non-HIV-infected participants at the University Hospital for Infectious Diseases in Zagreb, Croatia, from 2009-2011. CIMT measurement and determination of carotid plaque presence was detected by ultrasound. Adherence to the Mediterranean diet was assessed by a 14-point food-item questionnaire. Subclinical atherosclerosis was defined by CIMT≥0.9 mm or ≥1 carotid plaque. RESULTS: In HIV-infected patients, subclinical atherosclerosis was associated with older age (Plt;0.001; Mann-Whitney test), higher body mass index (P=0.051; Mann-Whitney test), hypertension (Plt;0.001; χ(2) test), and a lower Mediterranean diet score (P=0.035; Mann-Whitney test), and in non-HIV-infected participants with older age (P lt; 0.001; Mann-Whitney test) and hypertension (P=0.006; χ(2) test). Multivariate analysis showed that decreased adherence to the Mediterranean diet was associated with higher odds of subclinical atherosclerosis (odds ratio [OR] 2.28, 95% confidence interval [CI] 1.10-4.72, P=0.027) as was current smoking (OR 2.86, 95% CI 1.28-6.40), hypertension (OR 3.04, 95% CI 1.41-6.57), and male sex (OR 2.35, 95% CI 0.97-5.70). There was a significant interaction of age and HIV status, suggesting that older HIV-infected patients had higher odds of subclinical atherosclerosis than controls (OR 3.28, 95% CI 1.24-8.71, P=0.017 at the age of 60 years). CONCLUSION: We confirmed the association between lower adherence to the Mediterranean diet and increased risk of subclinical atherosclerosis and found that treated HIV infection was a risk factor for subclinical atherosclerosis in older individuals.

Acquired Methemoglobinemia in a Ketamine-induced Ulcerative Cystitis Patient: A Case Report.

INTRODUCTION: As ketamine gains traction as an alternative to opiates in the treatment of chronic pain, ketamine-induced ulcerative cystitis is now being recognized as a complication of its use. The first-line treatment is phenazopyridine, an over-the-counter medication for dysuria that historically has been known to cause methemoglobinemia. This report details the case of a patient presenting to the emergency department (ED) with methemoglobinemia. CASE REPORT: A 66-year-old woman with a complicated medical history presented to the ED with anemia and hypoxia after extended use of phenazopyridine for treatment of ketamine-induced ulcerative cystitis. She was found to have methemoglobinemia secondary to phenazopyridine used to treat her ketamine-induced ulcerative cystitis, a previously undocumented sequelae of chronic ketamine use. She was admitted to the hospital for three days and made a full recovery. CONCLUSION: This case highlights the need to suspect ketamine-induced ulcerative cystitis in patients who use ketamine chronically and be judicious in the use of phenazopyridine for symptom management to prevent life-threatening complications.

Hyperaldosteronism and Renal Artery Stenosis in a Post-Abdominal Aortic Aneurysm Patient: A Case Report.

INTRODUCTION: Patients with history of abdominal aortic aneurysm (AAA) undergoing surgical repair can have a myriad of surgical complications including compromise to large arteries branching from the aorta. Secondary hyperaldosteronism, characterized by high levels of aldosterone and renin, can be due to a multitude of causes, including renal artery stenosis, and presents with nonspecific symptoms of fatigue, increased thirst, and muscle spasms. While it can initially be difficult to diagnose given its multitude of metabolic abnormalities, secondary hyperaldosteronism is important to consider in patients presenting with uncontrolled hypertension, hypokalemia, and metabolic alkalosis. CASE REPORT: This report explores the case of a 65-year-old male with a complicated medical history presenting to the emergency department with hypokalemia and hypertension six months after undergoing endovascular repair for an AAA and was found to have metabolic abnormalities including hypokalemia and metabolic alkalosis consistent with secondary hyperaldosteronism, likely secondary to renal artery stent stenosis. He was admitted to the hospital for four days and made a full recovery. CONCLUSION: This case highlights the need to understand, identify, and accurately diagnose hyperaldosteronism and recognize post-AAA repair complications of renal artery stenosis as a cause of this metabolic derangement.

An Effective COVID-19 Medical Student Elective.

BACKGROUND: The COVID-19 pandemic has revealed the importance of teaching medical students pandemic preparedness and COVID-19 related clinical knowledge. To fill the gap of COVID-19 instruction backed by evaluation data, we present a comprehensive COVID-19 pilot curriculum with multiple levels of evaluation data. METHODS: In the spring of 2020, the University of California, Irvine (UCI) School of Medicine piloted a two-week, primarily asynchronous COVID-19 elective course for medical students. The goal of the course is to provide a foundation in clinical care for COVID-19 while introducing students to emerging issues of a modern pandemic. Objectives align with institutional objectives, and instruction is delivered in thematic modules. Our curriculum utilizes numerous instructional strategies effective in distance learning including independent learning modules (ILM), reading, video lectures, discussion board debates, simulation and evidence-based argument writing. We designed a three-level, blended evaluation plan grounded in the Kirkpatrick and Kirkpatrick evaluation model that assessed student satisfaction, relevance, confidence, knowledge and behavior. RESULTS: Our end of course survey revealed that students had high levels of satisfaction with the curriculum, and felt the course was relevant to their clinical education. Various assessment tools showed excellent levels of knowledge attainment. All respondents rated themselves as highly confident with the use of personal protective equipment, though fewer were confident with ventilator management. CONCLUSION: Overall our pilot showed that we were able to deliver relevant, satisfying COVID-19 instruction while allowing students to demonstrate knowledge and desired behaviors in COVID-19 patient care.

The Applied Weighted Slide Metric (AWSM) Tool: Creation of a Standard Slide Design Rubric.

Introduction: Lectures are a standard aspect across all realms of medical education. Previous studies have shown that visual design of presentation slides can affect learner outcomes. The purpose of this study was to develop a slide design rubric grounded in evidence-based, multimedia principles to enable objective evaluation of slide design. Method: Using the principles described in Mayers' Principles of Multimedia Learning and Duarte's Slide:ology, the authors extracted nineteen items important for slide design. We developed an online, rank-item, survey tool to identify the importance of each item among medical educators. Respondents selected which slide design principles they felt were important when attending a lecture/didactic session and ranked their relative importance. Results: We received 225 responses to the survey. When asked to specifically rank elements from most important to least important, participants gave the most weight to "readability of figures and data" and "[lack of] busy-ness of slide." The lowest ranked elements were "transitions and animations" and "color schemes". Using the results of the survey, including the free response, we developed a rubric with relative weighting that followed our survey data. Conclusion: With this information we have applied values to the various aspects of the rubric for a total score of 100. We hope that this rubric can be used for self-assessment or to evaluate and improve slides for educators. Future research will be focused on implementing and validating the slide design survey and ensuring it is easily usable with a high inter-rater reliability and whether self-assessment with the rubric improves presentation design and education quality.

Comparing the Psychological Effects of Manikin-Based and Augmented Reality-Based Simulation Training: Within-Subjects Crossover Study.

BACKGROUND: Patient simulators are an increasingly important part of medical training. They have been shown to be effective in teaching procedural skills, medical knowledge, and clinical decision-making. Recently, virtual and augmented reality simulators are being produced, but there is no research on whether these more realistic experiences cause problematic and greater stress responses as compared to standard manikin simulators. OBJECTIVE: The purpose of this research is to examine the psychological and physiological effects of augmented reality (AR) in medical simulation training as compared to traditional manikin simulations. METHODS: A within-subjects experimental design was used to assess the responses of medical students (N=89) as they completed simulated (using either manikin or AR) pediatric resuscitations. Baseline measures of psychological well-being, salivary cortisol, and galvanic skin response (GSR) were taken before the simulations began. Continuous GSR assessments throughout and after the simulations were captured along with follow-up measures of emotion and cortisol. Participants also wrote freely about their experience with each simulation, and narratives were coded for emotional word use. RESULTS: Of the total 86 medical students who participated, 37 (43%) were male and 49 (57%) were female, with a mean age of 25.2 (SD 2.09, range 22-30) years and 24.7 (SD 2.08, range 23-36) years, respectively. GSR was higher in the manikin group adjusted for day, sex, and medications taken by the participants (AR-manikin: -0.11, 95% CI -0.18 to -0.03; P=.009). The difference in negative affect between simulation types was not statistically significant (AR-manikin: 0.41, 95% CI -0.72 to 1.53; P=.48). There was no statistically significant difference between simulation types in self-reported stress (AR-manikin: 0.53, 95% CI -2.35 to 3.42; P=.71) or simulation stress (AR-manikin: -2.17, 95% CI -6.94 to 2.59; P=.37). The difference in percentage of positive emotion words used to describe the experience was not statistically significant between simulation types, which were adjusted for day of experiment, sex of the participants, and total number of words used (AR-manikin: -4.0, 95% CI -0.91 to 0.10; P=.12). There was no statistically significant difference between simulation types in terms of the percentage of negative emotion words used to describe the experience (AR-manikin: -0.33, 95% CI -1.12 to 0.46; P=.41), simulation sickness (AR-manikin: 0.17, 95% CI -0.29 to 0.62; P=.47), or salivary cortisol (AR-manikin: 0.04, 95% CI -0.05 to 0.13; P=.41). Finally, preexisting levels of posttraumatic stress disorder, perceived stress, and reported depression were not tied to physiological responses to AR. CONCLUSIONS: AR simulators elicited similar stress responses to currently used manikin-based simulators, and we did not find any evidence of AR simulators causing excessive stress to participants. Therefore, AR simulators are a promising tool to be used in medical training, which can provide more emotionally realistic scenarios without the risk of additional harm.

Fracture Detectives: A Fracture Review Match Game.

Audience: The target audience for this small group session is emergency medicine residents, primarily for use in didactic conference. This session can also be utilized with medical students or faculty looking to review various orthopedic injuries. Introduction: The Model of Clinical Practice of Emergency Medicine specifies content for American Board of Emergency Medicine certification and requires proficiency in a wide breadth of medical topics, including upper extremity and lower extremity orthopedic injuries.1 Traditional teaching sessions regarding orthopedic injuries usually rely on standard didactic presentations of injury description followed by review of imaging interpretations and management pearls. We present a novel use of gamification to tap into collective group knowledge to identify common orthopedic injuries. Our session then relies on the flipped classroom model, where learners teach relevant material to the rest of the cohort. Educational Objectives: At the end of this session, learners will be able to: recognize and identify various orthopedic injuries on plain film images, describe the mechanism of injury of the various orthopedic injuries, describe the physical examination findings seen in various orthopedic injuries, recall associated injuries and at-risk anatomic structures associated with various orthopedic injuries, and describe the emergency department management of various orthopedic injuries. Educational Methods: This session is grounded in two educational methods, gamification and the flipped classroom model. Gamification is implemented by being modeled after the popular group game, "Who Am I?" Learners are randomly given a paper card that has printed either the name of a common orthopedic injury or X-ray image of that injury. These cards are taped to the learner's back, without learners being aware of the diagnosis they are in possession of. By asking yes or no questions to others in the room, learners attempt to identify their specific diagnosis and find the pair that he or she matches with in the room. The educational strategy of flipped-classroom comes into play after all pairs are identified. Learners work in these paired groups to prepare one digital slide teaching the salient points related to their diagnosis. Learners all work on a shared Google Drive Slides document and present the material to the entire group at the end of the session. Research Methods: Educational content and satisfaction were obtained from learners through in-person interviews at the end of the session. Learners were asked questions regarding relevance, satisfaction with structure of the session, and overall value of the session related to their clinical practice. Results: Overall, residents had high levels of satisfaction after the session, many commenting on how gamification made the session more interactive and interesting. Learners did give feedback regarding needing more time to complete the flipped classroom component of the session, and overall felt like their parts of the presentation were rushed. Discussion: Gamification and flipped classroom learning strategies were effective in teaching the identification and management of common orthopedic injuries. Gamification increased engagement. Flipping the classroom allowed learners to obtain deeper knowledge in one specific diagnosis while learning collectively from the knowledge of an entire cohort. Topics: Extremity bony trauma, dislocations/subluxations, tendon injuries, ligamentous injuries.

Make and Break Your Own Hand: A Review of Hand Anatomy and Common Injuries.

Audience: The target audience for this small group session is emergency medicine residents, primarily for use in didactic conference. This session can also be utilized with medical students, or faculty looking to review relevant hand anatomy and common injuries. Introduction: Three-dimensional (3D) printing is an emerging technology that has the ability to produce highly accurate anatomic, cellular and medical device models. Limited research has shown promise in teaching anatomy,1 congenital heart disease2 and surgical pre-operative planning.3 Despite this potential, there is sparse evidence of 3D printing emergency medicine residency education. The Model of Clinical Practice of Emergency Medicine specifies content for American Board of Emergency Medicine certification and requires proficiency in a wide breadth of medical topics including upper extremity and hand injuries.4 The concepts of hand anatomy and function rely heavily on understanding spatial relationships between bones, tendons and ligaments. The instructional strategy of working with 3D printed hand models aligns with these learning goals. This project seeks to directly incorporate 3D printing into the orthopedic curriculum of emergency medicine residents during a required weekly didactic educational session. Educational Objectives: By the end of this session, learners should be able to name and identify all bones of the hand; arrange and construct an anatomically correct bony model of the hand; build functional phalangeal flexor and extensor tendon complexes onto a bony hand model; describe the mechanism of injury, exam findings, and management of the tendon injuries Jersey finger, Mallet finger, and central slip rupture; draw/recreate injury patterns on a bony hand model; and describe the mechanism of injury, exam findings, imaging findings, and management of scapholunate dissociation, perilunate dislocation and lunate dislocation, Bennett's fracture, Rolando fracture, Boxer's fracture and scaphoid. Educational Methods: This session was delivered in a small group session which utilized educational methods grounded in constructivist learning such as complex problem-solving, social negotiation, and spatial learning. Research Methods: Verbal feedback was obtained after the session. Results: Overall learners found the session engaging, interactive, and especially useful in demonstrating relevant hand anatomy and injuries. Learners felt that hands-on experience with the hand models reinforced knowledge and helped them better identify injuries in a spatial fashion. Topics: Extremity bony trauma, dislocations/subluxations, tendon injuries.

Family Game Show-style Didactic for Teaching Nervous System Disorders during Emergency Medicine Training.

Audience: Emergency medicine residents and medical students. Introduction: The field of emergency medicine requires learners to build a vast library of illness scripts to be accessible in a rapid manner. Illness scripts are refined and reinforced as senior physicians teach learners common associations between diagnoses, presentation, workup findings, and treatment modalities.1 In order to examine these associations, we developed a didactic session based on the popular television game show "Family Feud" to teach important neurologic conditions related to emergency medicine. This lecture was designed to be an interactive competition, leveraging group participation, competition, and expert opinion.Neurologic emergencies are very common, affecting millions of Americans yearly. It is important for emergency medicine physicians to quickly recognize these conditions and initiate treatment because delay can lead to devastating outcomes.2 The neurologic conditions covered in the lecture were chosen based on the 2016 EM model of clinical practice, sections 7.0: Head, ear, eye, nose, throat disorders, 10.0: Systemic infectious disorders, 12.0: Nervous system disorders, and 19.0: Procedures and skills integral to the practice of emergency medicine, as well as author experience. Educational Objectives: By the end of this didactic exercise the learner will: 1) name 13 important neurologic conditions related to emergency medicine: TPA (tissue plasminogen activator) contraindications/TPA eligibility, optic neuritis, botulism, giant cell (temporal) arteritis, viral encephalitis, neurocysticercosis, rabies, myasthenia gravis, neurosyphilis, status epilepticus, Bell's palsy, dementia vs. delirium, acute inflammatory demyelinating polyneuropathy (Guillain-Barré); 2) recognize five pattern words associated with each neurologic condition; 3) understand exam findings, diagnostic tests, and/or treatments for 13 important neurologic conditions. Educational Methods: A survey was sent through a national emergency medicine education listserv (Council of Residency Directors in Emergency Medicine [CORD-EM]) asking educators to list common word or phrase associations that come to mind with a list of neurological diagnoses. A PowerPoint lecture was created in the form of the game, Family Feud, using the data from this national survey. The game Family Feud requires participant teams to guess answers to certain questions by attempting to guess the most popular answers of survey respondents. At our weekly residency conference, residents were divided into teams and offered the opportunity to compete in a game testing knowledge of nervous system disorders. Each neurology topic was then addressed by a mini-lecture to review pertinent concepts in the disease process. There was no formal assessment at the end of this lecture; however, learners actively participated throughout the lecture. Questions were discussed at the end of each round giving learners the opportunity to fully understand topics. Research Methods: Efficacy of the educational content was assessed based on learner feedback as well as observation of the learners during the exercise. Results: Learners were engaged with the exercise and verbal feedback was uniformly positive. Learners were enthusiastic about the format and requested more sessions created in a similar game. Discussion: Based on feedback as well as observation of the learners, the lecture was both an effective highyield neurology refresher and team-building exercise. Learners enjoyed the opportunity to compete as a team. Gamification seemed to improve student enjoyment, engagement, and attention, which has also been shown in the literature.3 Our residency program intends to implement similar lectures in the future. Topics: Neurology, TPA contraindications, TPA eligibility, upper motor neuron lesion, lower motor neuron lesion, optic neuritis, aphasia, botulism, ACA (anterior cerebral artery) stroke, giant cell (temporal) arteritis, Bell's palsy, viral encephalitis, Todd's paralysis, neurocysticercosis, tonic-clonic seizure, rabies, epidural hematoma, myasthenia gravis, spinal cord injury, neurosyphilis, Glasgow Coma Score (GCS), status epilepticus, Horner's syndrome, subarachnoid hemorrhage, dementia, delirium, Parkinson's disease, acute inflammatory demyelinating polyneuropathy (Guillain-Barré).

Pediatric Seizure Team-based Learning.

Audience: The target audiences for this team-based learning are emergency medicine and emergency medicine-pediatric resident physicians. Introduction/Background: Pediatric seizure is a common presenting complaint in the emergency department. It is said that over 470,000 children have a diagnosed seizure disorder1 and 2%-5% of children aged 6 months to five years will have a febrile seizure at some point during childhood.2 While there are many published educational materials related to pediatric seizure, they are simulation-based, and/or isolated to management of one underlying diagnosis.3,4,5,6 Therefore, this team-based learning uses four cases to provide an understanding of the possible causes of seizure in children, as well as the management, workup, and disposition for emergency medicine residents in training. Educational Objectives: By the end of this TBL session, learners should be able to:Define features of simple versus complex febrile seizureDiscuss which patients with seizure may require further diagnostic workupSummarize a discharge discussion for a patient with simple febrile seizuresIdentify a differential diagnosis for pediatric patients presenting with seizureDefine features of status epilepticusReview an algorithm for the pharmacologic management of status epilepticusIndicate medication dosing and routes of various benzodiazepine treatmentsObtain a thorough history in an infant patient with seizures to recognize hyponatremia due to improperly prepared formulaChoose the appropriate treatment for a patient with a hyponatremic seizureDescribe the anatomy of a ventriculoperitoneal (VP) shuntRelate a differential diagnosis of VP shunt malfunctionCompare and contrast the neuroimaging options for a patient with a VP shunt. Educational Methods: This team-based learning is a classic TBL because it contains learner responsible content (LRC), an individual readiness assessment test (iRAT), a multiple-choice group RAT (gRAT) with immediate feedback assessment technique (IF/AT), and a group application exercise (GAE). Research Methods: We received formative feedback through conversations with learners afterwards, who stated they enjoyed the activity and felt it was highly useful for their learning; in addition, instructors discussed after the session and made changes accordingly. Results: We collected verbal feedback from instructors and learners after the session. Learners and instructors felt that it was very successful with limited modifications, in particular, the need for more time to complete the activity. Therefore, we suggest a 90 minute rather than 60-minute timeframe to adequately cover all material. Discussion: Pediatric seizure is a common complaint in the emergency department. It can be a difficult subject for the emergency medicine resident to master based on the variety of presentations. Indeed, the cause, management, and disposition may vary greatly; the etiology may range from benign to life-threatening, sometimes requiring minimal and at other times an extensive workup, with an ultimate disposition of either discharge home or admission to a pediatric intensive care unit. Therefore, team-based learning is well-suited to work through some of the complexities of such cases, and we found this educational session to be highly effective. Topics: Pediatric seizure, simple febrile seizure, complex febrile seizure, status epilepticus, hyponatremic seizure, ventriculoperitoneal (VP) shunt, team-based learning.