Development and Design of a Pediatric Case-Based Virtual Escape Room on Organophosphate Toxicity.

Audience: This case-based virtual escape room (VER) serves as a didactic activity suitable for learners who require an understanding of organophosphate toxicity. Educators may use this VER for distance-based learning in settings with adequate internet access. Introduction: India faces a concerning escalation in suicide rates, particularly among teenagers and young adults, often involving intentional pesticide ingestion, notably organophosphates.1-3 Our project addresses organophosphate ingestion by using a VER, a virtual learning platform adapted from in-person escape rooms to engage participants for educational purposes.4,5 Demonstrating success in medical, pharmacy, and nursing education, VERs increased satisfaction and competency among healthcare trainees compared to traditional learning platforms while fostering teamwork and communication in a virtual learning environment.6,7. Educational Objectives: By the end of the activity, learners should be able to: 1) recognize risk factors, symptoms, and presentation for organophosphate poisoning; 2) understand the radiologic and laboratory findings in organophosphate poisoning; 3) distinguish and differentiate electrocardiogram findings in common toxic ingestions; 4) explain the pathophysiology of organophosphate poisoning; 5) understand the importance of decontamination of the patient and personal protective equipment for staff for organophosphate poisoning; 6) describe the airway management of organophosphate poisoning; 7) describe the medical management of organophosphate poisoning, including antidotes and the correct dosing and 8) demonstrate teamwork through communication and collaboration. Educational Methods: The development process involved a seven-step approach, beginning with topic selection. The process involved creating a scenario, defining learning objectives, and designing an appropriate room. Clues and puzzles were tailored to align with the learning objectives and promote interactivity. The VER was hosted on Google Sites (Google LLC), accompanied by a facilitator guide offering content and technical support. Research Methods: This VER leverages technology for distance learning, using Zoom (Zoom Video Communications Inc.) for online sessions with EM trainees. Participants were organized into small groups in breakout rooms on Zoom, following a structured format that included a pre-briefing, a timed escape room scenario, debriefing, and evaluation. Afterward, an evaluation in the format of a survey was distributed to participants. This study was Institutional Review Board exempt. Results: Out of 120 participants in the VER, 50% responded to a survey. The majority found the activity interactive, engaging, and exciting. This feedback indicated a positive reaction to the VER, consistent with the Kirkpatrick model's first level of assessment.8 The VER effectively promoted learning and reinforced clinical knowledge, contributing to the second level of the Kirkpatrick model. In this case, 84.7% of respondents were able to identify knowledge gaps, and 84.2% of respondents found this to be a feasible model to reinforce medical knowledge. Discussion: This innovative VER addresses the value of distance-based learning in any setting with an internet connection. It has successfully enhanced collaboration and communication among participants in small groups, making it a valuable resource for medical education. This study has several limitations worth noting including a relatively low survey response rate. Baseline data was not collected prior to the VER. Additionally, the VER was not designed to be an open-book assessment; however, the absence of an in-person moderator makes it challenging to ascertain whether participants used external resources. Furthermore, the exclusive focus of this VER on a single topic may diminish its overall use compared to more traditional didactic sessions. This study is also limited by lack of long-term outcome data. Future studies could further assess knowledge improvement and clinical application. The authors plan to develop additional case-based VERs to advance EM trainees' knowledge, skills, and communication. Overall, the VER offers a promising and free educational tool for distance learning with potential benefits for various settings with internet access. Topics: Escape room, gamification, global health, organophosphate poisoning, simulation, virtual escape rooms.

Cardiac Point-of-Care Ultrasound in Pediatric Neurocritical Care: A Case Series.

BACKGROUND: Pediatric brain injury is accompanied by hemodynamic perturbations complicating the optimization of cerebral physiology. Point-of-care ultrasound (POCUS) uses dynamic real-time imaging to complement the physical examination and identify hemodynamic abnormalities in preload, contractility, and afterload conditions, but the contribution of cardiac POCUS in the context of pediatric brain injury is unclear. METHODS: We reviewed cardiac POCUS images integrated in clinical care to examine those with neurological injury and hemodynamic abnormalities. RESULTS: We discuss three children with acute brain injury and myocardial dysfunction identified using cardiac POCUS by bedside clinicians. CONCLUSIONS: Cardiac POCUS may have an important role in caring for children with neurologic injury. These patients received personalized care informed by POCUS data in attempts to stabilize hemodynamics and optimize clinical outcomes.

Case-Based Virtual Escape Rooms: Using Feedback to Change Online Platforms.

Introduction Virtual escape rooms (VERs) have provided education in healthcare settings. VERs were developed to provide medical education related to pediatric toxicology. This study explores simulation technologies, specifically portals to create and host VERs, including Google Sites, a website-building platform, and Articulate 360, an e-learning platform. The design objective was to create an engaging educational tool using a VER on two pediatric toxicology scenarios. Methods Case-based VERs were developed on Google Sites and Articulate 360. The cases focused on organophosphate toxicity and acute iron toxicity. Google Sites technology was used to build the organophosphate toxicity case, which was implemented and piloted with emergency medicine (EM) trainees in India and workshop participants at the International Pediatric Simulation Symposia and Workshops (IPSSW) in 2022. The iron toxicity case was developed using Articulate 360 and piloted at IPSSW in 2023. Feedback was collected as a survey from participants. Questions focused on using VERs as an engaging educational model, benefits, areas for improvement, and future participation in VERs. Following the study, a focus group meeting was held with facilitators and developers and subsequently analyzed. Results Evaluations from participants and a focus group provided data demonstrating both platforms' utility. Participants completed surveys after each VER. Overall, 84.2% of respondents (n=60) from EM training programs in India, 90.9% of respondents (n=11) from IPSSW in 2022, and 100% of respondents (n=23) from IPSSW in 2023 agreed or strongly agreed that this was an engaging education model. Conclusion Different platforms may be used to develop engaging VERs for gamification in education. This study found that VERs based on pediatric toxicology scenarios created on Google Sites and Articulate 360 are engaging educational tools for distance learning. Simulation technologies have benefits and disadvantages for Google Sites and Articulate 360. Simulation developers and educators should consider time, funding, technological needs, and participant feedback when deciding which portal to choose when building a VER.

Pediatric Code Cart Challenge for Emergency Medicine Trainees in Emergency Departments in India.

BACKGROUND: Code carts provide accessible emergency medication, supplies, and equipment to resuscitate a child. Unfortunately, there are limited studies on pediatric code cart use in resource-limited settings, including in India. METHODS: This was a Pediatric Code Cart Challenge for emergency medicine (EM) trainees in India. After receiving education on pediatric code carts, participants created their code carts and submitted a video showcasing their project. Reviewers evaluated each team's code cart using a rubric. A six-month follow-up survey assessed participants' use of code carts and their perception and satisfaction. RESULTS: Forty-nine participants across six sites completed the survey. The median number of pediatric code cart uses in the past six months was two. Materials frequently used from the code cart included medications (76%), followed by airway equipment (59%), and intravenous (IV) equipment (57%). Only 4% of respondents used an intraosseous (IO) catheter. Two of six sites reported modifying their code cart within the past six months by rearranging and/or adding equipment and medications. Local protocols, pediatric advanced life support guidelines, and references from other hospitals led to changes. Most respondents rated the pediatric code cart useful and appreciated its accessibility, ease of use, organization, and equipment. Respondents said they would add more pediatric equipment, including IO supplies, to improve their code cart. CONCLUSION: Participating sites now have pediatric medications and equipment accessible and organized in their code carts. Additionally, EM trainees learned what is needed and how to improve their current pediatric code carts. Future steps include expanding this pilot project to additional sites in low- and middle-income countries.

Examining the Association Between MIS-C and the Child Opportunity Index at a Single Center.

OBJECTIVE: To describe associations between the Child Opportunity Index (COI) and multisystem inflammatory syndrome of childhood (MIS-C) diagnosis among hospitalized children. METHODS: We used a retrospective case control study design to examine children ≤21 years hospitalized at a single, tertiary care children's hospital between March 2020 and June 2021. Our study population included children diagnosed with MIS-C (n = 111) and a control group of children hospitalized for MIS-C evaluation who had an alternative diagnosis (n = 61). Census tract COI was the exposure variable, determined using the patient's home address mapped to the census tract. Our outcome measure was MIS-C diagnosis. Odds ratios measured associations between COI and MIS-C diagnosis. RESULTS: Our study population included 111 children diagnosed with MIS-C and 61 children evaluated but ruled out for MIS-C. The distribution of census tract overall COI differed significantly between children diagnosed with MIS-C compared with children with an alternate diagnosis (P = .03). Children residing in census tracts with very low to low overall COI (2.82, 95% confidence interval [CI]: 1.29-6.17) and very low to low health/environment COI (4.69, 95% CI 2.21-9.97) had significantly higher odds of being diagnosed with MIS-C compared with children living in moderate and high to very high COI census tracts, respectively. CONCLUSION: Census tract child opportunity is associated with MIS-C diagnosis among hospitalized children suggesting an important contribution of place-based determinants in the development of MIS-C.

Plastic bronchitis secondary to bocavirus in a previously healthy 4-year-old with negative lymphatic evaluation.

This case of a child presenting with severe acute respiratory failure requiring extracorporeal membrane oxygenation due to plastic bronchitis demonstrates the possibility of developing this rare condition despite having no known underlying inflammatory or lymphatic issues. The normal lymphatic anatomy and flow in our patient several weeks after the acute illness suggests a transient lymphatic flow abnormality possibly driven by the acute lower respiratory tract infection with human bocavirus-1 (HBoV1). As there are now four patients in the literature identified with Plastic bronchitis (PB) in the setting of HBoV1, it may be beneficial to include HBoV1 in the initial workup of patients with unknown etiology of PB. While routine use of MR lymphangiography is not warranted, we wonder if the procedure might help realize lymphatic flow abnormalities crucial to the pathophysiology if it can be performed safely in the acute setting. The heterogeneous population presents a challenge when studying PB, thus future studies are needed to elucidate the complex pathophysiology, guide management, and better understand prognosis.

Case study: Cinnamon aspiration in a toddler causing severe ARDS requiring surfactant and extracorporeal membrane oxygenation.

As many as 6% of reported cinnamon poisonings cause significant clinical effects, however, descriptions of pulmonary toxicity have not yet been reported. Here, we present a pediatric patient's hospital course following powdered cinnamon aspiration. The early presentation with hypercapnia and lower airways obstruction evolved to hypoxemic respiratory failure and severe pediatric acute respiratory distress syndrome requiring a 7-day course of veno-venous extracorporeal membrane oxygenation, 16 ventilator-days, and three diagnostic and therapeutic bronchoscopies with two applications of surfactant therapy. The sum of these modalities contributed to this patient's survival and subsequent return to respiratory baseline 6 months post-hospitalization.

Disaster Training Following COVID-19 for Pediatric Medical Residents: Demand and Format.

OBJECTIVES: Assess the knowledge, confidence, and attitudes of residents toward disaster medicine education in the coronavirus disease 2019 (COVID-19) era. METHODS: Survey distributed to pediatric residents at a tertiary care center, assessing confidence in disaster medicine knowledge and skills, and preferred educational methods. Based on residents' responses, virtual and in-person educational session implemented with a postsurvey to analyze effectiveness of education. RESULTS: Distributed to 120 residents with a 51.6% response rate. Almost half (46.8%) of residents had less than 1 h of disaster training, with only 9.7% having experience with a prior disaster event. However, most residents were motivated to increase their knowledge of disaster medicine due to COVID-19 and other recent disasters, with 96.8% interested in this education as a curriculum standard. Simulation and peer learning were the most preferred method of teaching. Subsequent virtual and in-person educational session demonstrated improvement in confidence scores. However, 66.7% of the virtual subset conveyed they would have preferred in-person learning. CONCLUSIONS: COVID-19 has highlighted to trainees that disasters can affect all specialties, and pediatric residents are enthusiastic to close the educational gap of disaster medicine. However, residents stressed that, although virtual education can provide a foundation, in-person simulation is preferred for effective training.