An Appy That Needs Epi: An Atypical Presentation of Anaphylaxis.

Audience: This simulation is intended for 4th year medical students. Background: Shock is the result of inadequate circulation and failure to perfuse tissues, leading to cellular and organ dysfunction.1 Anaphylactic shock specifically is a type of distributive shock secondary to an IgE (immunoglobulin E) dependent reaction, which can result in respiratory compromise and cardiovascular collapse. The National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) laid out three diagnostic criteria for the diagnosis of anaphylaxis. Fulfillment of any one of the three following criteria likely indicates anaphylaxis: 1) acute onset of illness with skin findings and either respiratory compromise or reduced blood pressure, 2) involvement of two or more organ systems after exposure to a likely allergen, 3) reduced blood pressure after exposure to a known allergen.2 While not a required component of the pathology, hives and cutaneous findings often prompt clinicians to consider anaphylaxis in their differential diagnosis. However, skin findings are absent in 10-20% of cases of anaphylaxis.3 It is therefore important for physicians to quickly recognize anaphylactic shock and begin appropriate management in a timely manner even in the absence of skin findings. A previous study of fatal anaphylactic reactions showed a median time to respiratory or cardiac arrest as 30 minutes for foods, 15 minutes for envenomations, and five minutes for iatrogenic reactions.4 Drugs are the most common reported cause of fatal anaphylaxis in the United States,5 and penicillin allergy is the most common drug allergy reported by patients.6 This simulation will help learners recognize an atypical presentation of anaphylactic shock, encourage them to consider anaphylaxis in their differential diagnosis for decompensated patients, and reinforce the correct management of anaphylaxis. Educational Objectives: At the conclusion of the simulation, learners will be able to: 1) demonstrate ability to efficiently review patient records to optimize patient care and identify relevant details to current presentation, 2) rapidly assess a patient when there is a change in clinical status, 3) recognize the need to start resuscitative fluids for undifferentiated hypotension, 4) identify anaphylaxis, 5) demonstrate the medical management of anaphylaxis, 6) utilize the I-PASS framework to communicate with the inpatient team during the transition of care. Educational Methods: This summative simulation was designed to assess competence in two of the core Entrustable Professional Activities (EPAs), as defined by the Association of American Medical Colleges (AAMC). These include EPA 8 (Give or Receive a Patient Handover to Transition Care Responsibility) and EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). It was performed with 4th year medical students at the conclusion of their month-long emergency medicine (EM) clerkship. This scenario joined seven other scenarios in our pool of potential cases. These sessions are conducted using a high-fidelity manikin as the patient and a confederate/actor in the nursing role. After each scenario concludes, there is a post-simulation debriefing session on the presentation, differential diagnosis, physical exam findings, and management of the target pathology. A Gather-Analyze-Summarize technique was used for the debriefing session.7. Research Methods: Facilitators provided informal feedback to the scenario developers after the case was introduced into the assessment rotation. Learners completed a standard evaluation issued by the College of Medicine for the entire session, rather than for individual scenarios. These evaluations were reviewed in aggregate for the first year of implementation. Over this time frame, approximately half the students were run through this scenario. Results: Overall, our facilitators felt the case fit well into our pool of simulation cases. They felt they were adequately able to assess the students' ability to respond to a decompensating patient and thought the difficulty level was appropriate for 4th year medical students. The simulation assessment exercise as a whole was highly rated by the students. Of the 198 students who completed an evaluation, 93% rated the overall quality of the session as Very Good or Excellent. Discussion: Our department has run formative simulations during the 4th year EM clerkship for over ten years. Our primary objective is to assess 4th year students' competence in EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). This case was developed to replace another scenario of anaphylaxis which was felt to be too straightforward and easier than other scenarios in our repertoire. By making the scenario more difficult and the presentation of anaphylaxis a bit atypical, we were able to reinforce the need to include anaphylaxis in the differential diagnosis for any patient who rapidly decompensates. We are also able to review the diagnostic criteria for anaphylaxis and the appropriate treatment, including stopping the exposure to the antigen. This simulation proved to be highly engaging for 4th year medical students, and students seemed to perform at a similar level as previous summative simulations. Overall, we felt this simulation successfully achieved the objectives of the simulation session as a whole, and it was integrated into our 4th year EM clerkship simulation curriculum. Topics: Medical simulation, emergency medicine, anaphylaxis, anaphylactic shock, allergic reaction, penicillin allergy.

A First-Class Simulation: In-Situ In-Flight Medical Emergencies Curriculum for Emergency Medicine Residents Aboard a Commercial Airliner.

INTRODUCTION: In-flight medical emergencies occur in an estimated one out of 604 flights. Responding in this environment poses a unique set of challenges unfamiliar to most emergency medicine (EM) providers, including physical space and resource limitations. We developed a novel high-fidelity in-situ training curriculum focused on frequent or high-risk in-flight medical scenarios while replicating this austere environment. METHODS: Our residency program coordinated with our local airport's chief of security and an airline-specific station manager to arrange the use of a grounded Boeing 737 commercial airliner during late evening/early morning hours. Eight stations reviewing in-flight medical emergency topics were reviewed, five of which were simulation scenarios. We created medical and first-aid kits that reflect equipment used by commercial airlines. Residents' self-assessed competency and medical knowledge were assessed both initially and post-curriculum using a standardized questionnaire. RESULTS: Forty residents attended the educational event as learners. Self-assessed competency and medical knowledge increased after curriculum participation. All tested aspects of self-assessed competency had a statistically significant increase from a mean of 15.04 to 29.20 out of a maximum score of forty. The mean medical knowledge score increased from 4.65 to 6.93 out of 10 maximum points. CONCLUSION: A five-hour in-situ curriculum for reviewing in-flight medical emergencies increased self-assessed competency and medical knowledge for EM and EM-internal medicine residents. The curriculum was overwhelmingly well-received by learners.

Development of a Balloon Tamponade Task Trainer.

Variceal hemorrhage is a life-threatening complication of patients with cirrhosis. If a patient is hemodynamically unstable and unable to undergo endoscopic therapy, a balloon tamponade device may be placed to temporize the hemorrhage until definitive management may be performed. Placement of these devices may be performed by practitioners of several different medical specialties. Placement of balloon tamponade devices requires multiple steps and several different pieces of equipment. Performing the procedure incorrectly can lead to iatrogenic injuries such as esophageal necrosis or perforation. Since this is a relatively rare procedure often placed under high-stress situations, practicing in a low-stakes setting, such as a simulation lab, allows practitioners to hone their skills. Commercially available task trainers for balloon tamponade device placement are not available. In this paper, we describe how to modify an inexpensive airway task trainer for this purpose using commonly available and cost-effective materials.

Back in My Day: A Journal Club Using Landmark Articles for Emergency Medicine-Bound Medical Students.

This journal club style curriculum was developed to advance 4th year medical students in Emergency Medicine (EM) Milestone 19. The curriculum was introduced as part of a longitudinal boot camp course for EM- bound students. Students met monthly with faculty members to critically evaluate landmark articles within the field of EM. The curriculum culminated with student group presentations of two contemporary research articles with opposing conclusions. Discussed articles covered the following topics: stroke care, head trauma, cervical spine trauma, pulmonary embolism, cardiology treatments, syncope, post- cardiac arrest care, pediatrics, sepsis, and fluid resuscitation. The curriculum was evaluated using the institution's standard student educational session evaluation form. Students rated the quality of the sessions highly, and based on thematic review of comments, the journal club was a beneficial addition to the boot camp curriculum.