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Session Handout: CDEM- Innovations in Curricular Development
Session Directors: Nicholas Kman and Manon Kwon
Session Presenters: Brady Cox and David Gordon, Jonathon Davis and Eric Glasser, Michael Fitch and David Manthey, Lorraine Thibodeau
Session Planning Committee: Sorabh Khandelwal, Chairman; Butch Humbert, Nicholas Kman, Manon Kwon, Thomas Morrissey, Rob Rogers, Sarah Ronan-Bentle, Scott Sherman, Joshua Wallenstein
Session Objectives:
1. To report new and creative ways to teach medical students2. To expose participants to new curricula and allow them an opportunity to discuss these teaching styles with their creators3. Compose a resource guide of "Innovations in Medical Student Curriculum Development" to make available to medical student educators.**This is not a peer-reviewed publication and is independent of CORD/SAEM. Session Format:Panel discussion with 7 minute presentations in Powerpoint format. Session Length:1 hour
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Curricular Innovations to be presented at Session:
Development of a medical student teaching curriculum and tracking program for basic physician procedures
Michael T. Fitch, M.D., Ph.D.*David E. Manthey, M.D.Department of Emergency MedicineWake Forest University School of MedicineWinston-Salem, North Carolina
Corresponding author, [email protected]
Background: Basic clinical procedures are important for medical training. Recent studies report that only half of U.S. medical schools are rigorously teaching and evaluating technical procedures, and many schools do not require students to keep a log of completed procedures.Other work suggests that procedural skills, along with other basic clinical skills, should be taught, evaluated, and validated within the medical school curriculum.Objectives: Develop a new procedural curriculum to ensure that medical school graduates are competent in procedures considered essential for internship training, and create mechanisms for tracking and assessing competency in each procedure.Methods: Based on the results of a research study at our institution (Fitch, et al., 2008, Medical Teacher, in press), we identified a list of clinical procedures considered essential for medical students to learn prior to internship. A multi-disciplinary working group of medical educators was assembled from the Core Teaching Faculty of the medical school. This committee worked to identify, evaluate, and develop materials for teaching these procedures in a new medical student procedures curriculum. The Academic Computing department of our institution was enlisted to create a web-based tracking system for students to use during clinical clerkships.Results: A three part system was designed to implement the new procedures curriculum for 3rd and 4th year medical students: 1) an electronic self-study procedures curriculum using multimedia resources, 2) a web-based system to track students’ clinical procedure experiences, and 3) a direct-observation protocol for faculty evaluation of student competency on selected procedures. The first two parts of this new curriculum were successfully implemented in April of 2008. The electronic self-study procedures curriculum tracks student progress through the multi-media videos, handouts, and quizzes. The procedure tracking system records student procedures that are observed, participated in, performed unsuccessfully, and performed successfully. Positive feedback and constructive criticism from a student focus group and faculty members overseeing the clinical curriculum has been incorporated to improve the curriculum.Conclusions: A teaching curriculum and tracking program for basic physician procedures has been created and successfully implemented at our institution. The third component of the curriculum, competency testing for selected procedures, is planned for 2009. The successful launch of the curriculum this year has led to its identification by our educational leadership as a planned new longitudinal course for students in the 3rd and 4th years of our medical school.
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Development of a CLIPP-like computer-assisted learning tool
Lorraine Thibodeau, MD, FACEPClerkship DirectorDepartment of Emergency MedicineAlbany Medical CenterAlbany NY(518) [email protected]
Objective:The objective of this project was to develop a CLIPP-like computer-assisted learning tool to augment current educational practices for fourth year medical students in emergency medicine.
Methods:After reviewing current pediatric and medical CLIPP cases as well as the LCME and National Curriculum guidelines on core emergency medicine cases, the authors developed a set of computer-assisted vignettes covering ten topics that are essential to the practice of emergency medicine. Some of the computer-assisted modules were used to enhance learning in areas students would not otherwise have exposure, some were used to augment current didactic and small group topics, and two modules were employed to condense two core lectures on material that is covered on the final exam. At the end of the rotation students completed the same written final exam that has been employed for the past three years. The final exam only covered a subset of the material presented in the modules. Upon course completion students also filled out an evaluation of the computer-assisted module experience.
Results:One hundred and thirty-three students completed the computer-assisted modules over the course of one year. The final exam score mean (73%) remained the same as that of years previous to the introduction of the modules, even though two core lectures had been condensed and some exam question materials were only covered in the computer-assisted modules.
In their evaluations, 131 out of 133 (98%) students found the modules very useful and a good adjunct to other didactic methods, regardless of their specialty choice.
Conclusion:Computer-assisted learning modules can be used successfully to augment educational directives during a fourth year emergency medicine clerkship.
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Disaster Training for Students
Eric Glasser, M.D.; Jonathan E. Davis, M.D.; James D. Ott, R.N.; Yuri Millo, M.D.From the Department of Emergency Medicine, Georgetown University Hospital and Washington Hospital Center, Washington, D.C.
Educational purpose or rationale: Emergency preparedness training is critical for all types and levels of health care providers, including medical students. Although there is a trend among medical schools to incorporate disaster management principles into their curricula, it has been recognized that opportunities for hands-on, practical experience in disaster management is often lacking. Furthermore, our first-hand experience during the events of 9/11/01, as well as the 2001 anthrax attacks, highlighted the need for medical student members of provider response teams.
Design: Fourth year medical students rotating through the Emergency Department (ED) during their required senior clerkship receive a comprehensive online disaster management tutorial (17 modules, approximately 20 minutes each) covering chemical, biological, radiological, nuclear, and high yield explosive (CBRNE) response principles. Our students also play an integral role in our Department’s Hospital Disaster Life Support (HDLS) course.
Methods used for implementation: HDLS is a comprehensive, 2-day course on hospital disaster management response principles created and administered by our Department. It is unique in that it simultaneously trains the full spectrum of individuals likely to be encountered in an actual disaster (hospital personnel, pre-hospital personnel, hospital administration, support staff, as well as members of the community) in an integrated, multi-disciplinary fashion.
In addition to the online disaster management tutorial, students also receive interactive classroom instruction (covering CBRNE mass casualty incidents) during the HDLS course, and participate in mock disaster drills for “hands-on” experience. Students participate as either providers or disaster “victims,” which allows them to experience a mock disaster from multiple perspectives (360-degree approach).
Results (if applicable): We have created a database for cataloging student feedback regarding the training, and initial formative feedback has been very positive.
Conclusion: We provide our senior medical students with a unique, comprehensive, multidisciplinary training experience in hospital disaster management principles.
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Integrated Medical Student Critical Care Curriculum
David Gordon, MDDr. Brady Cox, PGY3 Duke University Medical Center Emergency Medicine Residency Program [email protected]
BACKGROUND: Emergency medicine clerkships play an important role in the education of medical students in critical care. We created a self-study learning module to formalize and standardize the critical care didactics medical students receive.
OBJECTIVES: The goal of this module is to focus the critical care education of fourth year rotating medical students onto five types of critically ill patients (Trauma, Stroke, Acute Coronary Syndrome, Respiratory Distress and Sepsis). Emphasis is placed on the important diagnoses, management steps, and procedures pertaining to these patients. In addition, medical students will be evaluated using patient simulation which allows them to act independently as the primary physician.
METHODS: The content of this module will focus on five types of critically ill patients to include patients presenting with Trauma, Stroke, Acute Coronary Syndrome, Respiratory Distress and Sepsis. For each category of patient, there is a written study guide with specific objectives to be used as self-instruction. The study guides focus on the initial assessment and stabilization, important interventions, and disposition of each patient. They also include additional resources such as CT brain tutorials, ECG tutorials, NIH stroke scales, procedure tutorials as well as 3-5 sentinel articles from the Emergency Medicine and Critical Care literature pertaining to each subject. Procedures are taught using low fidelity patient simulators in a 3 hour session during the clerkship. Evaluation of the students is a two step process including a written examination followed by a case scenario on the high fidelity simulator in which the student must apply their knowledge and demonstrate basic management skills.
RESULTS: As a new module, no results are available at this time. In the future, it is planned to evaluate the effectiveness of this curriculum through student performance on the written and patient simulation exams as well as student feedback.
CONCLUSIONS: A new curriculum on critical care has been created to formalize the instruction and assessment of fourth year medical students during their emergency medicine clerkship.
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Additional Innovations in Curricular Development (Not Presented at Session)
CLINICAL MEDICINE CORRELATION EXERCISES USING A HIGH FIDELITY SIMULATOR TO ENHANCE BASIC SCIENCE TEACHING David A. Wald, Gerald Sterling, Jane Cripe, James Heckman, Jeffrey Barrett, Thomas Costantino, Michael DeAngelis, Nina Gentile, Joseph Lex, James Ryan, Ronald Tuma Temple University School of Medicine Philadelphia, PA 19140 U.S.A. BACKGROUND: Use of high fidelity patient simulators is an important teaching modality to integrate basic science concepts with clinical medicine. We describe the implementation of educational exercises in the first two curricular years to bridge the gap between the classroom and the patient care setting. METHODS: Faculty from the departments of emergency medicine, pharmacology, and physiology developed three basic science – clinical correlation exercises, which were implemented during the 2007 – 2008 academic year (complete heart block – MS I students, tachyarrhythmias – MS II, acute exacerbation of asthma, and opioid overdose – MS II). Each case emphasized the basic science principles (physiology and / or pharmacology) as applied to the management of selected clinical conditions. The exercises were taught in small groups with a basic science and clinical faculty member using a high fidelity simulator (SimMan®). RESULTS: The basic science – clinical medicine correlation exercises were highly rated by all MS I and MS II students and were felt to be of substantial educational value in enhancing their knowledge of basic science, and integrating the knowledge in a clinical setting. In addition, all faculty felt that this approach promoted collegiality between the basic science and clinical faculty. CONCLUSION: High fidelity simulators can be used in a multidisciplinary fashion to bridge the gap between basic science and clinical medicine. Because of the positive response in its first year, we are planning on expanding the program during the 2008 – 2009 academic year.
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Advanced Topics in Emergency Medicine: An Honors Longitudinal Elective for Fourth Year Medical Students
Sorabh Khandelwal, MDNicholas E. Kman, MD146 Means Hall1654 Upham Dr.Columbus, OH 43210-1228Phone: 614-293-8305Fax: 614-293-3124E-mail: [email protected]
Background: Emergency medicine (EM) is a relatively young specialty and only recently has a dedicated curriculum been developed for use with medical students. Currently, many schools do not require students to complete a clerkship in EM. If they do, it is an overview of the specialty designed for students of all skill levels and career aspirations. We believe this brief glimpse at the specialty is not enough to prepare students to excel as residents. Currently no published honors curricula exist for exceptional students dedicated to a career in emergency medicine.
Objectives: We developed a ten-month longitudinal honors elective to teach advanced topics in EM to the most promising emergency medicine hopefuls, with the one overriding goal of producing the most capable and experienced residents possible.
Methods: A curriculum was developed that stressed the fourth year medical student’s progression to an outstanding emergency medicine resident. Residents and attendings are involved with most aspects of the course. Components of the curriculum include: journal club presentations, specialty-specific didactics, ATLS and PALS certification, high acuity code pager response, operating room experiences for tube thoracostomy and intubation, advanced suturing techniques, small group clinical lectures and skills lab scenarios, ultrasound, EMS lectures, grand rounds presentations, and teaching shifts with senior residents.
Results: Students participating in this elective have reported feeling well prepared to start residency. We hope to study each class prospectively (2007-2008 is the inaugural class) to determine their success in EM. We hope to examine whether they matched at their program of choice, whether they pursue a chief residency, a fellowship, or an academic position.
Conclusions: Although this is the first year for our honors elective, we feel that the students involved will be better prepared for a residency in emergency medicine than those just completing a one month clerkship.
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Wilderness Medicine in Preclinical Medical Student Education: Implications for Emergency Medicine Training
Matthew C. Dayno, MD, Andrew A. Monte, MD, Francis Renzi, MD. University of Massachusetts Medical School, Department of Emergency Medicine UMMHC.
Objectives: To use a novel course in wilderness medicine (WM) that employs simulation technology and techniques to reinforce pre-clinical medical students' understanding of the anatomy and physiology of medical and traumatic conditions, to increase their comfort with emergency situations, and to increase interest in emergency medicine (EM) as a career. Medical schools across the country have been moving to increase clinical content in the pre-clinical years. We propose that a didactic course in wilderness medicine designed for first- and second-year medical students would (1) strengthen anatomy and physiology topics encountered in basic science courses; (2) increase comfort in dealing with basic emergency and injury scenarios encountered in both hospital and recreational environments; and (3) increase interest in EM and EM subspecialties as a career choice.
Methods: The Wilderness Medicine Optional Enrichment (WMOE) elective is a full year course teaching students how to stabilize and treat patients with injuries in a challenging wilderness environment. The WMOE course provides an opportunity for the progressive development of students’ knowledge and skills in WM by integrating classroom based lectures, hands-on skill sessions using high-fidelity simulation center technology, and outdoor simulated patient encounters. The WMOE course introduces students to basic topics in EM and WM as well as the subspecialties of EMS, toxicology, and disaster medicine. The course consists of two classroom sessions that are half lecture and half hands-on skills and simulation stations taught in a small group format. The four outdoor sessions consist of multiple mock patient scenarios in which students encounter an EM resident actor or manikin portraying different injuries and/or disease states. Students are expected to evaluate, stabilize and treat the patient during the initial 20 minutes followed by a 20-minute debriefing and instruction period. Students learn basic patient assessment skills as well as core EM topics and clinical decision rules such as the Ottawa ankle rules and the NEXUS c-spine criteria during these stations. The anatomy and physiology of diseases are discussed in depth, allowing students to apply their classroom knowledge to a clinical setting. This ultimately leads to a more thorough understanding of the relevant anatomy and pathophysiology. The final outdoor session is a mock disaster scenario in which students are expected to apply the topics learned throughout the year to stabilize and initiate transport of multiple patients. Concepts of disaster management are introduced in an interactive lecture format at the end of the day.
Results: Course completion surveys show a high level of student satisfaction. Eighty-one percent of the students completed the survey in 2007-2008. The course had a median satisfaction rating of ten, an improvement over the previous year's median satisfaction rating of nine. Students felt that the course reinforced concepts learned in their basic science courses (median 9) and increased interest in EM (median 9).
Conclusion: A novel course in WM that uses simulation methodology can benefit preclinical medical students by reinforcing knowledge learned in basic science courses, increasing comfort with emergency situations, and increasing exposure to the field of EM.
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Value of SDOT for Medical Students Rotating Through Emergency Medicine
Tara Sheets, MD, Brent Passarello, MD, Josh Canning, MD, Wendy Nichols, RNChristiana Care Health System Department of Emergency Medicine 4755 Ogletown-Stanton Road, Room 1081 Newark, DE 19718 Office (302) 733-4150
Study Objectives: The purpose of this study is to determine if medical students rotating through Emergency Medicine (EM) who undergo the Standardized Direct Observational Tool (S-DOT) experience a change in their clinical performance as judged by an independent EM resident. Secondary objectives are to determine if students feel that the S-DOT has clarified their expectations for the emergency rotation and the student’s perception of the reflective accuracy of their own clinical practice while undergoing the S-DOT.
Methods: In this study, each student rotating through emergency medicine completed two S-DOT experiences during their rotation to measure their clinical performance. The student’s first S-DOT was completed by the observing resident during week one of the EM rotation, with feedback about the experience provided. Surveys were then completed by the students to evaluate the experience. Approximately two weeks later, the student was evaluated using a second S-DOT by the same resident. After the second S-DOT was completed with feedback, the student completed the same survey. Responses were recorded on a 10-point Likert Scale evaluating feedback received during the S-DOT experience and its utility in improving clinical practice, clarification of expectations for the rotation, accuracy of clinical practice during the S-DOT, and clinical improvement noted by resident after second S-DOT based upon initial S-DOT feedback. Mean response data was analyzed. All students rotating through our system between October 1, 2007 and March 30, 2008 were included in the study. Students were excluded if full data was not obtained.
Results: Complete data was collected from 17/26 students (65% response rate). Overall mean ratings were as follows: feedback received during the S-DOT experience (8.0 ±1.60), clarification of expectations for the rotation (6.7 ±2.39), accuracy of clinical practice during S-DOT (7.8 ±1.66), and clinical improvement noted by resident after second S-DOT based upon feedback from first SDOT (7.8 ±0.98).
Conclusion: Students felt S-DOT feedback was helpful in improving clinical performance, clarified their rotation expectations, and accurately reflected their clinical performance. Residents noted an improvement in student practice based upon S-DOT feedback.
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Development of an Advanced Core Clerkship in the Undifferentiated Patient for M3s
Michael D. Smith, MD; Louis S. Binder, MDMetroHealth Medical Center
BackgroundIn 2006, the Department of Emergency Medicine at MetroHealth Medical Center was charged by the Joint Curriculum Oversight Group at Case Western Reserve University School of Medicine to create a unique curriculum for the approach to the undifferentiated patient as part of an advanced core clerkship for third year medical students who have completed general clerkships in medicine, pediatrics, surgery, and obstetrics/gynecology. Within the setting of overall undergraduate curriculum reform at CWRU-SOM, four month-long mandatory experiences were created at the end of the M3 year (including the undifferentiated care month), in order to achieve additional educational objectives, and to provide for transition to the M4 year.
ObjectiveTo describe the developmental process and design of an undifferentiated care clerkship for all third year medical students at Case, sponsored by the Department of Emergency Medicine, and to evaluate data on students’ and faculty perceptions of the strengths, weaknesses, and overall quality of this new rotation.
MethodsThe curriculum was designed de novo to represent undifferentiated patients from a spectrum of clinical conditions. Learning objectives were proposed by the Committee on Medical Education (Curriculum; table 1). Department leaders at MetroHealth convened to develop the clerkship. It was decided that students would rotate through our emergency department with approximately half of the time spent on the acute side and the remainder spent in our non-acute unit. Students work in tandem with EM1 residents in providing “first contact” evaluation of undifferentiated patients, then present these “refined” patient workups formally to attending physicians for discussion and implementation. Students carry a shift card to record the variety of presentations seen during a shift and were instructed to write down at least one learning point per patient. They also carried “chief complaint portfolios” to monitor overall clerkship progress. Students were required to see set numbers for each chief complaint based on our ED census and percentages. A new set of lectures (greater than 20 hrs total lecture time) was written by the faculty on the approach to chief complaint portfolio the student is required to see (table 2). Participants in the clerkship presented directly to attending physicians. Students were evaluated by the clerkship director using both direct observation and reports from a computer-based evaluation system completed by faculty and residents. The clerkship students also completed an evaluation of their experience at the end of the clerkship.
ResultsOverall, the rated experience of the clerkship by the students was very high. On a Likert scale of 0 to 4 (0 lowest, 4 highest) the student evaluation data ranged from 3.3 to 4.0 on all rating scales (table 3). Free text data regarding strengths and weaknesses of the clerkship were also very positive. The feedback from the faculty is that this engendered a significant increase in their workload.
Conclusion
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The Department of Emergency Medicine at MetroHealth Medical Center successfully created a unique learning experience based on the approach to various chief complaints and the undifferentiated patient, meeting established objectives in medical education within the core undergraduate curriculum. This approach to patient evaluation is common to office-based and emergency department work-ups but contrary to how the majority of medical education is presented (disease based). Based on preliminary evaluation, students are exceeding the required numbers for their chief complaint portfolios. The students found the experience to be enlightening and enjoyable. Further work could include metrics to assess how this mode of education affects learning and knowledge retention.
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A Novel Integrated Simulation Experience for Pediatric Sepsis
Michael D. Smith, M.D.1; Thomas P. Noeller, M.D.1; Laura Holmes, M.D.2
1MetroHealth Medical Center Department of Emergency Medicine; 2Cleveland Clinic Department of Emergency Medicine
Introduction: MHMC/CCF/CWRU began to incorporate high fidelity and hybrid simulation into the residency curriculum in 2006 in conjunction with the Mt. Sinai Skills and Simulation Center (MSSSC). Opened in 2005, MSSSC is a free-standing multi-disciplinary center composed high-fidelity simulation rooms, one procedure room, a conference room, and several simulated exam rooms. Our first endeavor was a simulation experience, organized around a single theme (trauma), incorporating various simulation modalities with the goals of enhancing resident education and evaluating residents on the ACGME core competencies. Building on this experience, we developed hybrid simulation experience utilizing a pediatric resuscitation theme described here.
Objectives: 1) To develop a hybrid simulation experience related to a single theme 2) To assess the feasibility of a theme-centered hybrid simulation experience 3) To measure the impact of the simulation model on the results of standardized multi-choice testing 4) To measure ACGME core competencies using simulation modalities 5) To measure resident satisfaction with this simulation experience
Methods: Preparation time was approximately two months which included planning sessions, equipment procurement, written test and evaluation form development, and a “dry run” session with the chief residents. On the simulation day, in place of the program’s regularly scheduled 5-hour didactic block, thirty five residents were divided into groups of 4-5 and rotated through the following stations at thirty minute intervals: High fidelity simulation – A pediatric septic shock case was created involving seizure, airway management, shock management and cardiopulmonary arrest using Meti® “Ryan” Human Patient Simulator and was video-recorded from several angles. This was followed by a video debriefing using a standardized checklist of “critical actions.” Task Trainers – Distinct stations included advanced, vascular access, and lumbar puncture. All stations were precepted by faculty. The lumbar puncture station was also utilized to evaluate resident performance using standardized forms. Simulated Family discussion “breaking bad news” – Residents were given a brief written case scenario and had to break the bad news of a patient’s death to actors. The sessions were debriefed and video-recorded. Written test - a 27 question PALS-based multiple choice test was given before and after the simulation experience (matched for resident). Resident feedback - An anonymous electronic evaluation of the event was given to all residents.
Results: This hybrid, multi-station simulation experience for pediatric resuscitation was successfully completed and proven feasible. The results of the pre and post multiple choice test were not different statistically (pre test mean 20.76, SD 3.37, range 13-26; post test mean 19.8, SD 3.12, range 14-26, p=0.56). The majority of residents achieved competency based on CORD competency checklists: 93% were at or above expectations for the resuscitation module, whereas 100% were at or above expectations for the lumbar puncture module. The evaluation questionnaire showed an average rating of 3.97 on a 1 to 5 scale (1=not at all useful to 5=extremely useful), with very positive free text comments. The residents found the overall experience very useful.
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Conclusions: We successfully developed a theme-centered hybrid simulation experience to both train and evaluate EM residents in an approach to severe pediatric sepsis, seizure, and cardiopulmonary arrest. Our pediatric simulation experience did not statistically alter the outcome of a standardized MCQ pediatric knowledge test. We successfully measured core competencies using the simulation experience. We achieved a high level of resident satisfaction with the simulation experience. Evaluation of individual resident performance at the task trainer stations was anecdotally suboptimal in groups of 4-5 residents.
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A Novel Integrated Simulation Experience for Blunt Trauma
Michael D. Smith, M.D.1; Thomas P. Noeller, M.D.1; Laura Holmes, M.D.2
1MetroHealth Medical Center Department of Emergency Medicine; 2Cleveland Clinic Department of Emergency Medicine
Introduction: MHMC/CCF/CWRU began to incorporate high fidelity and hybrid simulation into the residency curriculum in 2006 in conjunction with the Mt. Sinai Skills and Simulation Center (MSSSC). Opened in 2005, MSSSC is a free-standing multi-disciplinary center composed of two high-fidelity simulation rooms, one video debriefing room, one procedure room, a conference room and several simulated exam rooms. We endeavored to create a simulation experience, organized around a single theme, incorporating various simulation modalities with the goals of enhancing resident education and evaluating residents on the ACGME core competencies.
Objectives: 1) To develop a hybrid simulation experience related to a single theme. 2) To assess the feasibility of a theme-centered hybrid simulation experience 3) To measure the impact of the simulation model on the results of standardized multi-choice testing 4) To measure ACGME core competencies using simulation modalities. 5) To measure resident satisfaction with this hybrid simulation model.
Methods: Preparation time was approximately two months which included planning sessions, equipment procurement, written test and evaluation form development, and a “dry run” session with the chief residents. On the simulation day, in place of the program’s regularly scheduled 5-hour didactic block, thirty five residents were divided into groups of 4-5 and rotated through the following stations at thirty minute intervals: High fidelity simulation – A multi injury trauma case was simulated using Meti® “Stan” Human Patient Simulator and was video-recorded from several angles. This was followed by a video debriefing using a standardized checklist of “critical actions. Task Trainers – Distinct stations included central line insertion, cricothyrotomy, thoracostomy tube placement, and retrograde urethrogram. All stations were precepted by faculty who evaluated resident performance using standardized forms. Simulated Family discussion “breaking bad news” – Both professional and amateur actors simulated patient family members, following a script outline. Residents were given a brief written case scenario and had to break the bad news of a patient’s death. The sessions were debriefed and video-recorded. Written test - a 25 question trauma-based multiple choice test was given before and after the simulation experience (matched for resident). Resident feedback - After the simulation day, an anonymous electronic evaluation of the event was given to all residents to complete.
Results: This hybrid, multi-station simulation experience for trauma care was successfully completed and proven feasible. There was no difference in pre- and post-multiple choice test scores (pre test mean 17.58, SD 3.41, range 13-25; post test 17.23, SD 3.2, range 12-24, p=0.56). The majority of residents were judged competent: 100% at or above expectations at all stations with the exception of the crichothyrotomy station (91% at or above expectations). The residents found the overall experience very useful.
Conclusions: We successfully developed a theme-centered hybrid simulation experience to both train and evaluate EM residents in an approach to multi-system trauma.
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Our trauma simulation experience did not statistically alter the outcome of a standardized MCQ trauma test. We successfully measured core competencies using the simulation experience. We achieved a high level of resident satisfaction with the simulation experience. Evaluation of individual resident performance at the task trainer stations was suboptimal in groups of 4-5 residents.
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Four Step Diagnosis of Abdominal Pain
Altaf H Ansari, M.D.Attending Physician, Emergency DepartmentBeth Israel Medical Center, New YorkAssistant Professor of Emergency Medicine,Albert Einstein College of Medicine, N.Y.Beth Israel Medical Center,Emergency Department16th Street at 1st Avenue,New York, N.Y. 10003Tel:(212) 420-2842Fax:(212) 420-2863e-mail: [email protected]
Step No: 1.
What pathological process is responsible for the patient’s abdominal pain?
This step requires drawing an Intensity-Duration Curve of the patient’s pain.
A. Did the pain start abruptly?
1. Tear/Rupture/Perforation 2.Abrupt Ischemia: Embolus
Dissection Torsion Spasm
B. Is it one fixed, escalating pain?
1. Fixed inflammation of an organ 2. Progressive distension of a hollow viscus or organ capsule.
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10 –
Intensity
0 – Time 0 ER Now Duration
CURVE #1
10 –
Intensity
0 – Time 0 ER Now Duration
CURVE #2
C. Does the pain come and go or vary in intensity- “Intermittent pain.”
1.Obstruction of a hollow viscus 2.Irritation of the lining of a hollow viscus.
There may also be any combination of these pathological processes and therefore Intensity-Duration curves, e.g.Right upper quadrant pain may start as intermittent, obstructive pain of Biliary Colic, and then progress to the fixed pain of inflammation, Cholecystitis.
Similarly, the intermittent renal colic of a kidney stone can become a progressive fixed pain of hydro-ureter when the stone gets impacted in the uretero-vesicular junction.
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10 –
Intensity
0 – Time 0 ER Now Duration
CURVE #3
10 –
Intensity
0 – Time 0 ER Now Duration
CURVE #4
10 –
Intensity
0 – Time 0 ER Now Duration
CURVE #5
Biliary Colic
Some Relief
Perforation
Cholesystitis
Inflammation
Also the fixed , progressive pain of Diverticulitis may abruptly increase to the point of rupture.
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10 –
Intensity
0 – Time 0 ER Now Duration
CURVE #6
Renal colic
UVP Stone with hydroureter
Step No: 2.Is the pain of Gastro-Intestinal or non Gastro-Intestinal origin:Ask about the functions of the Gastro-Intestinal tract, especially Ingestion and Excretion.What did the patient eat after the abdominal pain started, and what was the effect of eating on the pain.A. Pain got much worse. GI Tract in origin.B. No change in the intensity of pain. Non GI origin pain.C. Vomiting several times. Likely GI origin.D. Loose bowel movements several times. Likely GI origin.E. No bowel movement since the onset of pain, and not passed flatus. Likely GI origin (bowel obstruction )Most patients with abdominal pain will usually say “I have not eaten in many days” Asking “what did you try to eat last night or today?” will almost always give you a list of what they ate and it’s effect on the pain. Similarly ask when was the last time even a little bit of stools came out will be a helpful question for those patients who have not had a bowel movement in eight days.
Step No: 3.Which Organ is the pain originating from?:Ask about:A. Location of the pain.B. Radiation of the pain.
Think of all the organs that reside in the painful area of the abdomen, and also ask about the radiation of the pain since radiation is dependant on the innervation and, therefore, organ specifice.g aorta, pancreas and ureter to the back or flank, gall bladder to the right scapula, ureter to the groin, etc. Pain all over usually means either the small bowel or the entire peritoneum has the pathology.
RUQLUQ
RLQLLQ
Flank Flank
Epigast
Supra Pubic
Step No: 4.Combine the first three steps and come up with the pre-test probability of disease or diagnosis.
Some examples:1. Abrupt onset of mid abdominal pain, radiating to the back and flanks, with vomiting once only equals ruptured aortic aneurysm2. Abrupt onset of mid or generalized abdominal pain, not radiating to the back, but worse with meals may be mesenteric embolus and small bowel ischemia.3. Abrupt onset of right lower quadrant, not worse with eating, no radiation, no diarrhea, may be a ruptured ectopic pregnancy, ruptured cyst, or ovarian torsion.4.Progressive , fixed right lower quadrant pain, either worse with eating or with severe anorexia, no radiation to flank or groin may be appendicitis, whereas the same with eight episodes of diarrhea will more likely be colitis.5. Fixed, escalating left lower quadrant , not changed with eating, without diarrhea will likely be diverticulitis. ( Note that in diverticulitis the inflammation is para colic, not inside the colon, therefore, technically a non GI problem)
Limitations: The information necessary to draw the above pain curves should be rather accurate and reliable. Figuring out the timing of the patient’s pain depends on many factors including their mental status, level of intelligence, their pain tolerance, use of analgesics, etc. One should be very careful and painstakingly ask several questions to figure out if the pain was abrupt or not, and whether it is a constant and fixed or stuttering pain. Some helpful questions may be: When did the pain start? Couple of days or a while or a few days ago means non abrupt. A specific time, e.g. 3:AM usually means abrupt onset. How many minutes or hours did it take for your pain to reach a maximum intensity? Less than two minutes , or worst at the moment it started equals abrupt, and, quick, less than half hour means non abrupt. What were you in the middle of doing when the pain started? If the answer is a quick activity that normally takes less than a minute, e.g. sneezed, vomited or bent down to pick up something from the floor, usually means abrupt, and “was not doing anything” is more often not abrupt. Sometimes, even: So you do not think your pain got any worse after it started? No, it really did get much worse quickly, in less than half an hour, means not abrupt. Also it will be impossible to construct these pain graphs based on the information given by patients in case of young children, patients with decreased level of consciousness or altered mental status, or alcohol or drug dependence or those who have taken analgesics for this pain. Vomiting or loose bowel movements may also occur with non GI problems, e.g. vomiting with a myocardial infarct, or with renal colic, or loose bowel movement from aortic dissection due to the intensity of the pain and sympathetic discharge. However, it is usually only once or twice, and coincides with the severity of pain. Therefore, one should carefully inquire about the frequency and whether it was at the moment of the most intense pain.
Abdominal pain that got better with eating can certainly be due to duodenal ulcer, and therefore, GI in origin. Most of the patients whose pain disappeared after eating are much less likely to end up in our emergency department with complaint of abdominal pain, unless there is a change in the pain, e.g, abrupt, persistent pain of perforated ulcer with or without peritonitis. Location of the pain may not be accurate in patients whose intra-abdominal anatomy has been altered by previous surgery or a large mass, e.g. appendicitis in a near term patient may present as a fixed, persistent right flank pain resulting in a disastrous mis-diagnosis of pyelonephritis. Abdominal pain is not always due to a problem inside the abdominal cavity, and one must also inquire about symptoms of the neighboring heart and lungs, as well as consider the toxic, metabolic and environmental causes of abdominal pain. Lastly, while the process makes logical sense and works clinically, we have not looked at this prospectively or validated it. Doing so in the future may help in coming up with some clinical rules for application to most patients presenting with abdominal pain, and perhaps help not only in sharpening the clinical acumen of the medical students and young emergency physicians caring for patients with abdominal pain, but also help decrease radiation exposure, length of stay in the emergency department as well as reduce the cost of caring for some patients.
Technical support by Mr. Mark Gorelick, BIMC., N.Y.
