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.

Strategies for case-based training with virtual patients: An experimental study of the impact of integrating mental model articulation and self-reflection.

Resilient system performance in high-stakes settings, which includes the ability to monitor, respond, anticipate, and learn, can be enhanced for trainees through simulation of realistic scenarios enhanced by augmented reality. Active learning strategies can enhance simulation-based training, particularly the mental model articulation principle where students are prompted to anticipate what will happen next and the reflection principle where students self-assess their performance compared to a gold standard expert model. In this paper, we compared simulation-based training for trauma care with and without active learning strategies during pauses in the simulated action for progressively deteriorating patients. The training was conducted online and real-time without a facilitator, with 42 medical students viewing training materials and then immediately taking an online quiz for three types of trauma cases: hemorrhage, airway obstruction, and tension pneumothorax. Participants were randomly assigned to either the experimental or control condition in a between-subjects design. We compared performance in the control and experimental conditions based on: A) the proportion of cues correctly recognized, B) the proportion of accurate diagnoses, C) the proportion of appropriate treatment interventions, and D) verbal briefing quality on a 1-5 scale. We found that the training intervention increased recognition of subtle cues critical for accurate diagnosis and appropriate treatment interventions; the training did not improve the accuracy of diagnoses or the quality of the verbal briefing. We conclude that incorporating active learning strategies in simulation-based training improved foundational capabilities in detecting subtle cues and intervening to rescue deteriorating patients that can increase the readiness for trainees to contribute to resilient system performance in the high-stakes setting of emergency care in hospitals.

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.

Level I Hyperglycemia Alert: A Case Report.

INTRODUCTION: Nonketotic hyperglycemia-associated chorea is a rare condition that upon presentation to the emergency department can be easily misdiagnosed as a seizure or a stroke. Although uncommon, identification of this condition can aid emergency physicians in avoiding unnecessary and potentially harmful treatments for other neurological pathology. Furthermore, prompt hyperglycemic control can result in reversal of symptoms within days. CASE REPORT: We present a case of nonketotic hyperglycemia-associated chorea where the patient was transferred to our facility as a hemorrhagic stroke alert, based on a false-positive interpretation of head computed tomography (CT) imaging. CONCLUSION: Nonketotic hyperglycemia on CT imaging and clinical presentation can mimic stroke presentations. Prompt recognition of key features can lead to appropriate treatment.

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.

Procedural Curriculum to Verify Intern Competence Prior to Patient Care.

INTRODUCTION: Emergency medicine (EM) programs train residents to perform clinical procedures with known iatrogenic risks. Currently, there is no established framework for graduating medical students to demonstrate procedural competency prior to matriculating into residency. Mastery-based learning has demonstrated improved patient-safety outcomes. Incorporation of this framework allows learners to demonstrate procedural competency to a predetermined standard in the simulation laboratory prior to performing invasive procedures on patients in the clinical setting. This study describes the creation and implementation of a competency-based procedural curriculum for first-year EM residents using simulation to prepare learners for supervised participation in procedures during patient care. METHODS: Checklists were developed internally for five high-risk procedures (central venous line placement, endotracheal intubation, lumbar puncture, paracentesis, chest tube placement). Performance standards were developed using Mastery-Angoff methods. Minimum passing scores were determined for each procedure. Over a two-year period, 38 residents underwent baseline assessment, deliberate practice, and post-testing against the passing standard score to demonstrate procedural competency in the simulation laboratory during intern orientation. RESULTS: We found that 37% of residents required more than one attempt to achieve the minimum passing score on some procedures, however, all residents ultimately met the competency standard on all five high-risk procedures in simulation. One critical incident of central venous catheter guideline retention was identified in the simulation laboratory during the second year of implementation. CONCLUSION: All incoming first-year EM residents demonstrated procedural competence on five different procedures using a mastery-based educational framework. A competency-based EM curriculum allowed for demonstration of procedural competence prior to resident participation in supervised clinical patient care.

A Different Type of Tension Headache: A Case Report of Traumatic Tension Pneumocephalus.

Tension pneumocephalus is a rare neurosurgical emergency requiring cranial decompression to prevent permanent neurological injury, herniation, and death. In this report, we present a trauma patient struck by a knife in the forehead who presented with agitation and vomiting. Imaging ultimately revealed a minimally displaced frontal sinus fracture through both the anterior and posterior walls of the sinus. This disruption, acting as a ball-valve for air entry into the cranium, resulted in extensive pneumocephalus and eventual tension physiology. The patient required immediate neurosurgical decompression. This case illustrates both the importance in recognition of this uncommon pathology as well as the need for rapid reassessment with clinical changes in trauma patients. Topics: Tension pneumocephalus, facial fracture, head trauma.

Preparing students for residency interviews in the age of COVID: Lessons learned from a standardized video interview preparation program.

Objectives: The COVID-19 pandemic has necessitated the widescale adoption of video-based interviewing for residency applications. Video interviews have previously been used in the residency application process through the pilot program of the American Association of Medical Colleges standardized video interview (SVI). We conducted an SVI preparation program with our students over 3 years that consisted of an instructional lecture, deliberate practice in video interviewing, and targeted feedback by emergency medicine faculty. The aim of this investigation was to summarize the feedback students received on their practice SVIs to provide the guidance they need for preparing for the video interviews that will replace in-person interviews with residency programs. Methods: A retrospective thematic analysis was conducted on faculty feedback provided to students who had completed SVI practice videos in preparation for their application to an EM residency between June 2017 and July 2019. Categorized comments were also sorted by type of faculty feedback: positive reinforcement, constructive criticism, or both. Results: Forty-six medical students received 334 feedback elements from three faculty. Feedback was balanced between positive reinforcement statements and constructive criticism. Students performed well on appearance and attire, creating a proper recording environment, and response content. They needed the most guidance with the delivery of content and the technical quality of the video. Conclusions: Our results demonstrate a need for formal instruction in how to communicate effectively through the video medium. Medical educators will need to formally prepare students for tele-interviews with residency programs, with an emphasis on communication skills and techniques for improving the quality of their video presentation, including lighting and camera placement.

Redesign of a Piston for a Diesel Combustion Engine to Use Biodiesel Blends.

Biofuels represent an energy option to mitigate polluting gases. However, technical problems must be solved, one of them is to improve the combustion process. In this study, the geometry of a piston head for a diesel engine was redesigned. The objective was to improve the combustion process and reduce polluting emissions using biodiesel blends as the fuel. The methodology used was the mechanical engineering design process. A commercial piston (base piston) was selected as a reference model to assess the piston head's redesign. Changes were applied to the profile of the piston head based on previous research and a new model was obtained. Both models were evaluated and analyzed using the finite element method, where the most relevant physical conditions were temperature and pressure. Numerical simulations in the base piston and the new piston redesign proposal presented similar behaviors and results. However, with the proposed piston, it was possible to reduce the effort and the material. The proposed piston profile presents adequate results and behaviors. In future, we suggest continuing conducting simulations and experimental tests to assess its performance.

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.

Asteroids® and Electrocardiograms: Proof of Concept of a Simulation for Task-Switching Training.

INTRODUCTION: Emergency physicians are interrupted during patient care with such tasks as reading electrocardiograms (ECGs). This phenomenon is known as task-switching which may be a teachable skill. Our objective was to evaluate the potential of a video game for simulating the cognitive demands required of task-switching. METHODS: Emergency medicine residents took a pretest on ECG interpretation and then a posttest while attending to a video game, Asteroids®. RESULTS: The 35 residents (63%) who participated, scored worse on the ECG posttest then they did on the pretest (p<.001; effect size=1.14). There were no differences between genders or training level. CONCLUSION: Interpreting ECGs while playing the Asteroids® game significantly lowered ECG interpretation scores. This shows the potential of this activity for training residents in task-switching ability. The next phase of research will test whether ECG reading performance while task-switching improves with practice.

Diseño mecánico de un exoesqueleto para rehabilitación de miembro superior / Mechanical design of an exoskeleton for upper limb rehabilitation

El ritmo de vida actual, tanto sociocultural como tecnológico, ha desembocado en un aumento de enfermedades y padecimientos que afectan las capacidades físico-motrices de los individuos. Esto ha originado el desarrollo de prototipos para auxiliar al paciente a recuperar la movilidad y la fortaleza de las extremidades superiores afectadas. El presente trabajo aborda el diseño de una estructura mecánica de un exoesqueleto con 4 grados de libertad para miembro superior. La cual tiene como principales atributos la capacidad de ajustarse a la antropometría del paciente mexicano (longitud del brazo, extensión del antebrazo, condiciones geométricas de la espalda y altura del paciente). Se aplicó el método BLITZ QFD para obtener el diseño conceptual óptimo y establecer adecuadamente las condiciones de carga de servicio. Por lo que, se definieron 5 casos de estudio cuasi-estáticos e implantaron condiciones para rehabilitación de los pacientes. Asimismo, mediante el Método de Elemento Finito (MEF) se analizaron los esfuerzos y deformaciones a los que la estructura está sometida durante la aplicación de los agentes externos de servicio. Los resultados presentados en éste trabajo exhiben una nueva propuesta para la rehabilitación de pacientes con problemas de movilidad en miembro superior. Donde el equipo propuesto permite la rehabilitación del miembro superior apoyado en 4 grados de libertad (tres grados de libertad en el hombro y uno en el codo), el cual es adecuado para realizar terapias activas y pasivas. Asimismo, es un dispositivo que está al alcance de un mayor porcentaje de la población por su bajo costo y fácil desarrollo en la fabricación.

The pace of modern life, both socio-cultural and technologically, has led to an increase of diseases and conditions that affect the physical-motor capabilities of persons. This increase has originated the development of prototypes to help patients to regain mobility and strength of the affected upper limb. This work, deals with the mechanical structure design of an exoskeleton with 4 degrees freedom for upper limb. Which has the capacity to adjust to the Mexican patient anthropometry (arm length, forearm extension, geometry conditions of the back and the patient's height) BLITZ QFD method was applied to establish the conceptual design and loading service conditions on the structure. So, 5 quasi-static cases of study were defined and conditions for patient rehabilitation were subjected. Also by applying the finite element method the structure was analyzed due to service loading. The results presented in this work, show a new method for patient rehabilitation with mobility deficiencies in the upper limb. The proposed new design allows the rehabilitation of the upper limb under 4 degrees of freedom (tree degrees of freedom at shoulder and one at the elbow), which is perfect to perform active and passive therapy. Additionally, it is an equipment of low cost, which can be affordable to almost all the country population.

Diseño personalizado de una interfaz mioeléctrica para una prótesis de miembro superior / Custom design of a myoelectric interface for upper limb prostheses

Desde los años sesenta se utilizan las señales electromoigráficas (EMG) como señales de control para prótesis actuadas por servomotores, así como en la estimulación de músculos que sufren de parálisis o de atrofia parcial. Mediante el avance tecnológico se ha logrado mejorar el diseño, así como la fabricación de sistemas protésicos, que funcionan como extensiones de algún miembro del cuerpo humano, agregando además con los nuevos diseños, características básicas como: flexibilidad, estética morfológica, incremento de la relación resistencia/peso así como multifuncionalidad. Una prótesis mioeléctrica es una estructura desarrollada con el fin de reemplazar una parte o la totalidad de un miembro del cuerpo humano, lo mismo que suplir las funciones perdidas de este, sin dejar de lado la imagen corporal del paciente. Estas prótesis son accionadas por actuadores que se controlan a través de señales EMG, las cuales se obtiene mediante agujas intramusculares superficiales o por medio de electrodos colocados en el muñón del paciente. Este tipo de prótesis es cada vez más aceptado por personas con amputación de mano, ya que proporciona un mejor desempeño y permite el incremento de funcionalidad para el paciente que la utiliza, debido a que su control es más sencillo.

Since 60’s electromiographical signals (EMG’s) are used like a control signals for prostheses acted by servomotors, as well as stimulation of muscles that are affected due to partial or total paralysis. By means of technological advance, it has been possible to improve the design as well as the production of prosthetic systems that work as extensions of some member of human body, adding with the new designs also basic characteristics as: flexibility, aesthetic morphology, and superior strength/weight relationship, as well as multi-functionality. Mioelectric prosthesis is a structure developed with the purpose of replacing a part or the entirety member of human body, same as to replace the lost functions of this, without leaving aside patient's corporal image. These prostheses are acted by actuators that are controlled through EMG signals, which are obtained by means of intramuscular or superficial needles, or by means of electrodes placed in patient's stump. This class of prostheses is more and more accepted by people with hand amputation since it provides a better acting, that which allows a superior functionality for patient that uses it, because its control is simpler.

Análisis numérico de una prótesis endobronquial utilizada para el tratamiento de cáncer pulmonar / Numerical analysis of intrabronchial prosthesis used for the treatment of lung cancer

En México, la mortalidad debido a enfermedades bronco-respiratorias se ubica en el sexto lugar según datos estadísticos dados por el Instituto Nacional de Enfermedades Respiratorias (INER). Esto genera la necesidad de incrementar la eficiencia en la aplicación de los tratamientos usados para este tipo de patología. Algunos de los métodos utilizados con mayor frecuencia para el tratamiento de estas dolencias hacen uso de micro dispositivos, también conocidos como válvulas endobronquiales. Este es un sistema alternativo que evita cirugías invasivas y logra prolongar e incrementar la calidad de vida de los pacientes. En este trabajo se presenta el análisis del desempeño de la válvula IBV®. Para el desarrollo del estudio numérico se determinaron las dimensiones y propiedades mecánicas del modelo a partir de catálogos del fabricante. Se desarrolló un modelo para el cual se consideraron las propiedades del Nitinol® y Silastic®. Asimismo, se propusieron dos condiciones de operación para la válvula, una anclada en el bronquio y la otra en la condición en la que se encuentra plegada dentro del broncoscopio. Se utilizó el Método del elemento finito (MEF) para simular las condiciones de trabajo de la válvula. Los resultados encontrados muestran el funcionamiento estructural y el nivel de los esfuerzos generados en el implante durante el ciclo de respiración forzada del individuo. Además, se proporcionan las bases para generar un nuevo dispositivo que pueda emular el funcionamiento de este tipo de implantes y aumente la eficiencia del tratamiento de dicha patología.

In Mexico, the mortality rate due to bronchial respiratory sickness is placed in the sixth position, according to statistics from the National Institute of Breathing Sickness (INER), so it is convenient to increment the efficiency of treatments for those pathologies. The intrabronchial valve is a recommended alternative method; being it main objective to avoid invasive surgery and increase the time and quality of patient´s life. Within this work a biomechanical analysis of an IBV® valve is carried out. Regarding the numerical analysis, the dimensions and mechanical properties of the valve were proposed based on catalogues published by the manufacturer as more reliable information was not available in the open literature. As a result, a new model was developed in which both materials Nitinol® and Silastic® are considered as the main valve materials. The proposed working conditions assume that the valve is implanted in folded form at the bronchus and then anchored when it is unfolded. Finite Element Method (FEM) was used to simulate the proposed working conditions. Results obtained show the structural performance and the level of stress generated in the implant during the breathing cycle. In addition, it provides the knowledge to generate a new device that could emulate the performance of these implants and develop a more efficient treatment this disease.