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Audience: This content can be used for trauma centers, emergency medicine residency programs, and emergency nursing. Introduction: Mass casualty incidents (MCI) are becoming increasingly common and are occurring in locations that have not experienced them previously which adds to the challenge of readiness for emergency departments (EDs). Sporadic occurrences and limited resources add to the complexity of preparing for such an event. In advance of a large gathering in our metropolitan area, we developed and conducted a simulation to better prepare not only our residents, but our MCI planning committee, registered nurses (RNs) and emergency room technicians (ERTs) for an MCI.Emergency medicine is at the forefront of any hospital's response to an MCI. These events stretch the resources and force EDs to function differently than usual.1 Responding effectively is crucial to minimizing the morbidity and mortality of our patients while maximizing use of available resources. We can improve our level-headedness, efficiency, and department and hospital-level planning through simulation. This has particular implications for residency training with effects on education, preparedness, and wellness. Educational Objectives: The learners will (1) recognize state of mass casualty exercise as evidenced by verbalization or triaging by START (Simple Triage and Rapid Treatment) criteria, (2) triage several patients, including critically ill or peri-arrest acuities, according to START criteria, (3) recognize the need to limit care based on available resources, as evidenced by verbal orders or communication of priorities to team, and (4) limit emergency resuscitation, given limited resources, by only providing treatments and employing diagnostics that do not deplete limited time, staffing, and space inappropriately. Educational Methods: A small-scale, high-fidelity simulation was created to replicate the pace and acuity of patients presenting in an MCI. Three critically injured patients with multiple gunshot wounds, represented by high-fidelity manikins with moulaged wounds, were presented over a 6-minute span. The team was allowed 10 minutes total to conduct life-saving measures, targeted evaluation, and disposition of the patients. The simulation was then adapted for use in a second institution's simulation center to replicate and validate the objectives given a different system. Research Methods: The learners were immediately verbally debriefed and feedback of the simulation, fidelity and appropriateness of the experience solicited. Unprompted, several of the learners volunteered that the efficacy of the experience was highly educational and valuable. Anonymized digital feedback was requested in the form of an online survey and was generally positive.The educational content was created by experts in simulation medicine and validated by content experts in the fields of Emergency Medicine, Trauma Surgery and Emergency Nursing. Results: After the scenario ended, the learners were taken to a second room for debriefing by a trauma surgeon, an emergency medicine attending, and the nurse trauma educator. The actors were able to participate as secondary learners and were rotated out of simulation duties to participate in the debriefing. After this twenty-minute educational debrief, the learners were brought back to the simulation bay and were given a similar scenario. After this iteration, the team debriefed a second time. This hour schedule of cases and debrief was repeated a total of four times with a total of twelve individual learners. Suggestions and verbal feedback were noted for incorporation into appropriate committees or hospital departments. No formal assessment was done and inclusion was strictly on a voluntary basis. An evaluation of the session (on a Likert scale of 1-5) had six respondents which showed an average of 5 on how educational the session was, 4.8 on how realistic the session was, and 4.8 on how effective the session was. Discussion: Simulation allows participants to safely gain practical experience in MCI management. The experience was well-received, and the learners verbalized increased confidence should they encounter an MCI in the future. We developed this simulation to give residents and nurses first-hand experience performing under high-stress, resource-limited conditions. We also had other learners observing the process which allowed for productive debriefing and planning for improvement. The ideas generated from this ultimately became part of the hospital's MCI response plan. The main takeaways were triage strategy and limited resource management. Topics: Mass casualty incident, mass gathering, penetrating trauma, high-fidelity simulation, team-based simulation, trauma center, hospital response planning.
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Audience: The Zipperator training model is designed for emergency medicine resident physicians and physicians. Introduction: Zipper entrapment injuries are an uncommon cause of penile injury in the emergency department, representing an incidence of less than 0.5% of pediatric emergency department visits.1 However, they are one of the most common causes of genital injuries in young boys.1,2 Various methods proposed for releasing the entrapped tissue range from the use of mineral oil as lubrication to techniques to release the zipper mechanism or, in extreme cases, surgical procedures.3-6 A well-designed simulated task trainer would allow learners to practice these methods in a controlled environment conducive to learning 7,8. Given the low frequency of the chief complaint and with a wide variety of release techniques available, the purpose of this study was to build a simulation model that could improve learner confidence in troubleshooting this rarely performed procedure. Although past studies have designed similar task trainers, this novel model was built using a low-cost device ("Operation") to provide real-time alarm noises that reasonably simulate distress and procedural anxiety for both the patient and provider. Although pain and anxiety are separate outcomes from zipper entrapment release, including a component of these emotions may mimic the same emotional states that patients, their parental unit, and perhaps their provider may experience regarding this chief complaint given its rarity, anatomic vulnerability, and the overall sensitivity of the complaint's nature. Educational Objectives: After training on the Zipperator, learners will be able to:Demonstrate at least two techniques for zipper release and describe how methods would extrapolate to a real patient.Verbalize increased comfort with the diagnosis of zipper entrapment.Present a plan of care for this low-volume, high-anxiety presentation. Educational Methods: As part of a voluntary Emergency Medicine curriculum at two different sites, we constructed an inexpensive model for penile zipper entrapment using a household gameboard, "Operation," and materials that are easily obtainable and assembled in any emergency department. "Operation" was selected for its ability to produce alarm noises in response to excessive movement, which would reasonably simulate distress and procedural anxiety that may be experienced by both the patient and provider. This task trainer was used to teach medical students and post graduate year (PGY) 1-4 resident learners. A brief hypothetical situation was presented to learners, highlighting patient and paternal unit anxiety. Following this, learners were given a survey and asked to complete pre-model training questions immediately prior to using the simulated model. Learners were then given the opportunity for hands-on skills-based practice. Postmodel training questions were made available in the same survey immediately following the exercise. Research Methods: This exercise was offered at two sites over a two-year period. Sixty learners participated in the exercise. Participation was voluntary, was not graded nor shared with the residency director, and all feedback was formative in nature. Selected faculty and research assistants provided asynchronous opportunities for learners to practice on the model. Before the exercise, the faculty or research assistant on site presented a brief hypothetical situation to simulate patient and paternal unit anxiety that could be expected in this chief complaint. Each learner was then allowed to select a variety of tools and methods to practice zipper entrapment release. Learners were asked to begin a survey prior to training on the model, and then complete the survey immediately after training on the model to evaluate its educational value. The survey created for this study consisted of a structured questionnaire that contained close-ended questions. Measures evaluated include experience with prior zipper entrapments, comfort with zipper entrapments before and after training on the simulated model, and user experience. Results: Before the exercise, 68.3% of learners described their comfort with managing future zipper entrapments as very uncomfortable or totally uncomfortable. Although only 8.3% of learners had treated the zipper entrapment complaint prior to the exercise, 100% of those who had experienced treating the complaint felt that the simulated model was at least somewhat reflective of their experience with a real patient. 71.7% of the learners found the experience enjoyable, although 20% found the experience totally unenjoyable, of note, for unclear reasons and with unclear significance or etiology. After the exercise, 71.7% of learners indicated they felt comfortable to very comfortable regarding future cases of zipper entrapment. Discussion: Through the use of a well-known household board game and supplies commonly found in the emergency department, we created a simulated model that could be easily replicated. This simple model provided practice of the hand motions necessary for zipper entrapment release, as well as familiarity with the mental and physical approaches to dislodging the entrapment. The resident physicians who had had a prior zipper entrapment patient reported the model was somewhat similar to actual patient encounters. Overall, this model was well-received by the learners, with most expressing it was enjoyable and feeling it increased their confidence for treating this chief complaint. Some learners had noted the experience was totally unenjoyable. This measure may not be an appropriate endpoint, however, and incongruencies may be addressed by implementing prizes or friendly competition for enjoyment. Another limitation of this study is the leap taken between movement and patient comfort. While possible that learners can manipulate the model to reduce movement of the needle without meaningful reduction in zipper movement, observation by the instructor was sufficient to ensure this finding was not observed in our learner population. We therefore submit this cheap, simple model as a potential method to teach approaches to teaching a low frequency, high anxiety chief complaint. Topics: Penile entrapment model, penile entrapment release, Emergency Medicine, Urology, Clinical/Procedural Skills Training.
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Ogilvie's syndrome (acute colonic pseudo-obstruction) is a rare disorder characterized by an acute dilation of the colon measuring greater than 10 centimeters. Common symptoms associated with Ogilvie's include abdominal distension, abdominal pain, nausea, vomiting, constipation, and diarrhea. This report presents an uncommon case of a quadriplegic presenting to the emergency department with complaints of abdominal distention. Computed tomography and radiographic imaging studies were consistent with Ogilvie's syndrome. The patient was admitted to the hospital and started on stool softeners and bowel rest with resolution of symptoms. Topics: Ogilvie's syndrome, quadriplegic, abdominal distension, colonic pseudo-obstruction.