Not Just a Pain: A Medical Simulation Case About Biased Communication and Osteomyelitis in Pediatric Sickle Cell Anemia.

Introduction: Biases in communication can be harmful to patient perceptions of care and the medical team's decision-making. Optimal communication must be taught and practiced similarly to the optimal management of the complex medical conditions associated with sickle cell disease (SCD). This simulation is designed to teach about biases, optimizing communication to and about a patient with SCD, and appropriately diagnosing and managing pediatric osteomyelitis as a complication of SCD. Methods: We designed and implemented a simulation case targeting emergency medicine residents and fellows to raise awareness about biases associated with SCD care and the complication of osteomyelitis in children with SCD. The case was delivered as a scheduled educational activity. Guided debriefing about optimizing care and communication for this patient population followed the simulation. We measured outcomes based on facilitator field notes and participant evaluations (Likert-scale and open-response questions). Results: Forty learners of varying medical practice proficiencies, societal experiences, and demographics participated, with 30 completing the postsimulation feedback survey. A majority (97%) of participants indicated that the experience was useful and would improve their clinical performance. Participants learned from each other's language and communication styles and reflected on their own communication. Discussion: Overall, participants found the simulation very useful as a review of the medical diagnosis and management of osteomyelitis in pediatric SCD. Moreover, they were very engaged and interested in the opportunity to learn about communication biases, particularly as these relate to SCD, to optimize their patient care.

Peripartum Cardiomyopathy.

Audience: This simulation is appropriate for emergency medicine (EM) residents of all levels. Introduction: Peripartum cardiomyopathy (PPCM) is a rare, idiopathic condition that occurs in the mother around the time of childbirth. Heart failure with reduced ejection fraction and/or reduced systolic function diagnosed in patients during the last month of pregnancy or up to five months following delivery defines PCCM.1 Another broader definition from the European Society of Cardiology defines PPCM as heart failure that occurs "towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found."2 Though PPCM occurs worldwide, most data is extracted from the United States (incidence 1:900 to 1:4000 live births), Nigeria, Haiti, and South Africa.3,4Risk factors for PPCM include pre-eclampsia, multiparity, and advanced maternal age. Unfortunately, the complete pathophysiology of PPCM remains unclear. However, it is important for emergency physicians to be aware of this rare diagnosis because though 50-80% of women with PPCM may eventually recover normal left ventricle systolic function,5 positive outcomes depend on timely recognition of PPCM as a disease and the appropriate management of heart failure. Symptomatic PPCM is an emergent condition that requires an attentive and knowledgeable emergency medicine physician for rapid recognition and treatment. A simulation of this rare condition can give residents the experience of identifying and managing this disease that they might not otherwise see personally during their training. Educational Objectives: By the end of this simulation session, learners will be able to: 1) initiate a workup of a pregnant patient who presents with syncope, 2) accurately diagnose peripartum cardiomyopathy, 3) demonstrate care of a gravid patient in respiratory distress due to peripartum cardiomyopathy, 4) appropriately manage cardiogenic shock due to peripartum cardiomyopathy. Educational Methods: This simulation was conducted as a high-fidelity medical simulation case followed by a debriefing. It could potentially be adapted for use as a low-fidelity case or an oral boards exam case. Research Methods: The educational content and clinical applicability of this simulation was evaluated by oral and written feedback from participant groups at a large three-year emergency medicine residency training program. Each participant completed the case and the facilitated debriefing afterwards. Case facilitators also provided their personal observations on the implementation of the simulation. Results: The participants gave the simulation positive feedback (n=18). Seventeen EM residents and one pediatric emergency medicine (PEM) fellow participated in the feedback survey. Learners overall agreed (18.75%) or strongly agreed (81.25%) that participating in this simulation would improve their performance in a live clinical setting. Discussion: Peripartum cardiomyopathy is a low frequency, high acuity illness that requires a synthesis of the learner's knowledge of complex physiology, navigation of logistical and systems-based challenges, and advanced communication and leadership skills to ensure the best possible patient outcome. All EM physicians will be expected to expertly manage this illness after completion of an EM training program, yet not every EM resident will encounter this type of patient during training. Supplementing the EM resident's standard training with this simulation experience provides a psychologically and educationally safe space to learn and possibly make mistakes without causing patient harm. Practically all residents were able to correctly diagnose the patient with a cardiomyopathy even if they were not familiar with the diagnosis of "peripartum cardiomyopathy." The residents particularly enjoyed the case to explore concepts of benefits and risks of medical therapeutics (ie, positive pressure ventilation, vasopressors/inotropes) and safe practice for the gravid patient. This case and the associated high yield debriefing session were effective teaching tools for emergency medicine residents about PPCM. Topics: Medical simulation, peripartum cardiomyopathy, pregnancy, respiratory failure, cardiogenic shock, emergent cesarian section.