Novel Academic Tabletop 2022 (NAT22): A Dynamic Dice-Based Emergency Medicine Education Tool.

Gamification is an effective teaching tool that improves engagement and knowledge retention. Tabletop role-playing games are dynamic games that use random chance and foster player/leader partnership. To date, there are no teaching tools that mimic dynamic or unpredictable patient presentations. This style of game may work well as a tool for medical education in a simulation-based modality. In this report, we document the rules, materials, and training required to reproduce a hybrid game created to combine facets of simulation and tabletop role-playing games (TRPGs) to create a dynamic medical education tool. After testing the game for flaws and fluidity of gameplay, we plan to collect data evaluating emergency medicine residents' enjoyability and knowledge retention. In this article, we describe a novel TRPG simulation hybrid game that we hypothesize will improve learner enjoyability/engagement and have similar educational benefits to standard medical education.

Little Patients, Big Tasks - A Pediatric Emergency Medicine Escape Room.

Audience: The target audience for this small group session is post-graduate year (PGY) 1-4 emergency medicine (EM) residents, pediatric EM (PEM) fellows, and medical students. Introduction: Pediatric emergency department visits have been declining since the start of the COVID-19 pandemic, leading to decreased exposure to pediatric emergency care for EM residents and other learners in the ED.1 This is a major problem, given that the Accreditation Council for Graduate Medical Education (ACGME) mandates that a minimum of 20% of patient encounters or five months of training time for EM residents must occur with pediatric patients, with at least 50% of that time spent in the ED setting.2,3 A minimum of 12 months must be spent in the pediatric ED for PEM fellows,2 and an average of 7.1 weeks of medical school are spent in pediatric clerkships.4 This decrease in pediatrics exposure in the post-pandemic environment can be addressed through simulation and gamification. We selected the gamification method of an escape room to create an engaging environment in which learners could interface with key pediatric emergency medicine clinical concepts via group learning. Educational Objectives: By the end of this small group exercise, learners will be able to:Demonstrate appropriate dosing of pediatric code and resuscitation medicationsRecognize normal pediatric vital signs by ageDemonstrate appropriate use of formulas to calculate pediatric equipment sizes and insertion depthsRecognize classic pediatric murmursAppropriately diagnose congenital cardiac conditionsRecognize abnormal pediatric electrocardiograms (ECGs)Identify life-threatening pediatric conditionsDemonstrate intraosseous line (IO) insertion on a pediatric modelDemonstrate appropriate use of the Neonatal Resuscitation Protocol (NRP®) algorithms. Educational Methods: An escape room - a form of gamification - was utilized to engage the learners in active learning. Gamification is an increasingly popular educational technique being utilized in graduate medical education and refers to the conversion of serious, non-trivial material into a fun activity fashioned like a game in order to enhance engagement in learning.5 This educational method seeks to enhance knowledge, attitudes, and skills via components of games - such as puzzles and prizes - outside of the context of a traditional game.6 Though high-quality research data on the effectiveness of gamification methods in graduate medical education is limited, studies have shown that gamification enhances learning, attitudes, and behaviors.5,7 One randomized, clinical-controlled trial investigating the use of gamification to enhance patient outcomes found that patients of primary care physicians randomized to the gamification group reached blood pressure targets faster than in the control group.8 Escape rooms as a modality for education have been suggested to improve active learning and enhance learner engagement in the learning process.9 In an escape room, learners are "locked" in an artificial environment (whether digitally or in person) and must utilize their group or individual knowledge to solve puzzles and escape from their "entrapment."9,10 Escape rooms utilized as part of EM residency didactic training have demonstrated learner enthusiasm,11,12 desire to repeat the activity again,13 preference for escape rooms over traditional learning methods,14,15 improved confidence in communication and leadership skills,11,15 and improvement scores from pre- to post-testing.16We developed an escape room in which learners were divided into teams and informed that they would need to "escape" from our resident lounge by successfully completing all nine stations. The first team to complete all nine stations would win a prize. Only after the last team completed the ninth station and debriefing was complete could all teams be "freed" from the escape room. Research Methods: Learners provided anonymous online survey feedback regarding the quality of the educational content and the efficacy of the delivery method. Results: A post-participation survey was disseminated to 55 residents, 32 of whom attended the PEM Escape Room, with a response rate of 9% (3/32 residents). One hundred percent of respondents felt that the activity content was applicable to their needs as an emergency physician. The session was rated as excellent by 33.3% of respondents, and 66.7% of respondents rated the session as above average. A second survey was disseminated seven months after the event to the 24 remaining residents who attended the event, with a response rate of 46% (11/24 residents); eight attendees had graduated at the time of this survey dissemination. Results of the second survey indicated that 100% (24/24 residents) felt that the activity content was applicable to their needs as an emergency physician, 73% (17/24 residents) rated the session as excellent, and 27% (7/24 residents) rated the session as above average. Discussion: Though we received limited survey responses (3/32 on the first survey and 11/24 on the second survey), respondents felt that the educational content met their learning needs and was of high quality. We had six faculty members present to facilitate the escape room while there were four groups of residents (eight per group). The ideal faculty to resident ratio would be one faculty member per group with three to six players, based on prior literature showing that teams of more than six players take longer to complete escape room tasks.17,18 We also recognized the importance of sending out the feedback survey link early because we believe the delay in our survey being emailed to the residents contributed to the low response rate (three trainees).One participant provided the following feedback: "I think the 'escape room' struck an excellent balance with regard to trying to address knowledge that was relevant but also obscure or difficult enough that group/collaborative effort was required. I enjoyed the process and low stakes atmosphere." This quote nicely summarizes our take-aways: That the PEM escape room incorporates key tenets of adult learning theory. Also known as andragogy, adult learning theory posits that adult learners are self-directed, have prior life experiences that shape their learning process, learn for practical reasons (ie, choose to learn in order to fulfill the demands of their social role), and are problem-oriented in their learning.19 Though andragogy does not technically apply only to adults (as many children are self-directed learners),20 having an understanding of the practical and experiential nature via which adults approach learning allows the adult educator to appropriately cater educational activities to meet the adult learner's needs.This escape room aligned with the core tenets of adult learning theory in several ways. Specifically, residents were given autonomy of participation in the escape room and thus had to take initiative to promote their own learning.21 Topics featured in the escape room stations were selected based on their clinical challenges and high-yield for board examinations and patient care, making their relevance immediately obvious to learners; this is a key feature of catering to adult learners.22 The escape room provided a comfortable and collegial environment in which residents felt comfortable learning, fostering an ideal setting for mature learners.21 Direct and immediate feedback are key components of adult learning theory, and faculty members were physically present to provide feedback at each escape room station.22 Finally, working in teams required the learners to engage in active learning rather than acting as passive recipients of cognitive information.21 Thus, the PEM escape room serves as an ideal framework to meet the needs of the adult learner. Topics: Pediatrics, emergency medicine, pediatric emergency medicine.

Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo: A Systematic Review and Meta-analysis.

Importance: Acute vertigo can be disabling. Antihistamines and benzodiazepines are frequently prescribed as "vestibular suppressants," but their efficacy is unclear. Objective: To assess the efficacy of antihistamines and benzodiazepines in the treatment of acute vertigo from any underlying cause. Data Sources: We searched the PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and ClinicalTrials.gov databases from inception to January 14, 2019, without language restrictions. Bibliographies of the included studies and relevant reviews were also screened. Study Selection: We included randomized clinical trials (RCTs) comparing antihistamine or benzodiazepine use with another comparator, placebo, or no intervention for patients with a duration of acute vertigo for 2 weeks or less. Studies of healthy volunteers, prophylactic treatment, or induced vertigo were excluded, as were studies that compared 2 medications from the same class. Data Extraction and Synthesis: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, data were extracted and risk of bias was assessed by 2 authors independently for each study. Data were pooled using a random-effects model. Main Outcomes and Measures: The predefined primary outcome was change in 10- or 100-point vertigo or dizziness visual analog scale (VAS) scores at 2 hours after treatment. Secondary outcomes included change in nausea VAS scores at 2 hours, use of rescue medication at 2 hours, and improvement or resolution of vertigo at 1 week or 1 month. Results: Of the 27 trials identified in the systematic review, 17 contributed to the quantitative meta-analysis and involved a total of 1586 participants. Seven trials with a total of 802 participants evaluated the primary outcome of interest: single-dose antihistamines resulted in significantly more improvement on 100-point VAS scores compared with benzodiazepines (difference, 16.1 [95% CI, 7.2 to 25.0]) but not compared with other active comparators (difference, 2.7 [95% CI, -6.1 to 11.5]). At 1 week and 1 month, neither daily benzodiazepines nor antihistamines were reported to be superior to placebo. RCTs comparing the immediate effects of medications (at 2 hours) after a single dose generally had a low risk of bias, but those evaluating 1-week and 1-month outcomes had a high risk of bias. Conclusions and Relevance: Moderately strong evidence suggests that single-dose antihistamines provide greater vertigo relief at 2 hours than single-dose benzodiazepines. Furthermore, the available evidence did not support an association of benzodiazepine use with improvement in any outcomes for acute vertigo. Other evidence suggested that daily antihistamine use may not benefit patients with acute vertigo. Larger randomized trials comparing both antihistamines and benzodiazepines with placebo could better clarify the relative efficacy of these medications.

Fluid Resuscitation and Progression to Renal Replacement Therapy in Patients With COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with respiratory symptoms and renal effects. Data regarding fluid resuscitation and kidney injury in COVID-19 are lacking, and understanding this relationship is critical. OBJECTIVES: To determine if there is an association between fluid volume administered in 24 h and development of renal failure in COVID-19 patients. METHODS: Retrospective chart review; 14 hospitals in Indiana. Included patients were adults admitted between March 11, 2020 and April 13, 2020 with a positive test for severe acute respiratory syndrome coronavirus 2 within 3 days of admission. Patients requiring renal replacement therapy prior to admission were excluded. Volumes and types of resuscitative intravenous fluids in the first 24 h were obtained with demographics, medical history, and other objective data. The primary outcome was initiation of renal replacement therapy. Logistic regression modeling was utilized in creating multivariate models for determining factors associated with the primary outcome. RESULTS: The fluid volume received in the first 24 h after hospital admission was associated with initiation of renal replacement therapy in two different multivariate logistic regression models. An odds ratio of 1.42 (95% confidence interval 1.01-1.99) was observed when adjusting for age, heart failure, obesity, creatinine, bicarbonate, and total fluid volume. An odds ratio of 1.45 (95% confidence interval 1.02-2.05) was observed when variables significant in univariate analysis were adjusted for. CONCLUSIONS: Each liter of intravenous fluid administered to patients with COVID-19 in the first 24 h of presentation was independently associated with an increased risk for initiation of renal replacement therapy, supporting judicious fluid administration in patients with this disease.

Can we predict which COVID-19 patients will need transfer to intensive care within 24 hours of floor admission?

BACKGROUND: Patients with COVID-19 can present to the emergency department (ED) at any point during the spectrum of illness, making it difficult to predict what level of care the patient will ultimately require. Admission to a ward bed, which is subsequently upgraded within hours to an intensive care unit (ICU) bed, represents an inability to appropriately predict the patient's course of illness. Predicting which patients will require ICU care within 24 hours would allow admissions to be managed more appropriately. METHODS: This was a retrospective study of adults admitted to a large health care system, including 14 hospitals across the state of Indiana. Included patients were aged ≥ 18 years, were admitted to the hospital from the ED, and had a positive polymerase chain reaction (PCR) test for COVID-19. Patients directly admitted to the ICU or in whom the PCR test was obtained > 3 days after hospital admission were excluded. Extracted data points included demographics, comorbidities, ED vital signs, laboratory values, chest imaging results, and level of care on admission. The primary outcome was a combination of either death or transfer to ICU within 24 hours of admission to the hospital. Data analysis was performed by logistic regression modeling to determine a multivariable model of variables that could predict the primary outcome. RESULTS: Of the 542 included patients, 46 (10%) required transfer to ICU within 24 hours of admission. The final composite model, adjusted for age and admission location, included history of heart failure and initial oxygen saturation of <93% plus either white blood cell count > 6.4 or glomerular filtration rate < 46. The odds ratio (OR) for decompensation within 24 hours was 5.17 (95% confidence interval [CI] = 2.17 to 12.31) when all criteria were present. For patients without the above criteria, the OR for ICU transfer was 0.20 (95% CI = 0.09 to 0.45). CONCLUSIONS: Although our model did not perform well enough to stand alone as a decision guide, it highlights certain clinical features that are associated with increased risk of decompensation.

Characteristics of COVID-19 patients with bacterial coinfection admitted to the hospital from the emergency department in a large regional healthcare system.

INTRODUCTION: The rate of bacterial coinfection with SARS-CoV-2 is poorly defined. The decision to administer antibiotics early in the course of SARS-CoV-2 infection depends on the likelihood of bacterial coinfection. METHODS: We performed a retrospective chart review of all patients admitted through the emergency department with confirmed SARS-CoV-2 infection over a 6-week period in a large healthcare system in the United States. Blood and respiratory culture results were abstracted and adjudicated by multiple authors. The primary outcome was the rate of bacteremia. We secondarily looked to define clinical or laboratory features associated with bacteremia. RESULTS: There were 542 patients admitted with confirmed SARS-CoV-2 infection, with an average age of 62.8 years. Of these, 395 had blood cultures performed upon admission, with six true positive results (1.1% of the total population). An additional 14 patients had positive respiratory cultures treated as true pathogens in the first 72 h. Low blood pressure and elevated white blood cell count, neutrophil count, blood urea nitrogen, and lactate were statistically significantly associated with bacteremia. Clinical outcomes were not statistically significantly different between patients with and without bacteremia. CONCLUSIONS: We found a low rate of bacteremia in patients admitted with confirmed SARS-CoV-2 infection. In hemodynamically stable patients, routine antibiotics may not be warranted in this population.

First-time Diabetic Ketoacidosis in Type 2 Diabetics With Covid-19 Infection: A Novel Case Series.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 is a novel coronavirus first diagnosed in U.S. hospitals in January 2020. Typical presenting symptoms include fever, dry cough, dyspnea, and hypoxia. However, several other symptoms have been reported, including fatigue, weakness, diarrhea, and abdominal pain. We have identified a series of patients with diabetic ketoacidosis (DKA) likely precipitated by coronavirus disease 2019 (COVID-19). CASE SERIES: We describe 5 patients with previously known type 2 diabetes and no history of DKA, who presented to the emergency department with new-onset DKA and COVID-19. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Diabetes mellitus is a known risk factor for poor outcomes in viral respiratory illnesses, including COVID-19. Infection may precipitate DKA in patients with type 2 diabetes. Aggressive management of these patients is recommended; however, management guidelines have not yet been put forth for this unique subset of patients.