A comprehensive collection of medical revision notes that cover a broad range of clinical topics. Inspect the urine currently in the catheter bag and note its appearance (e.g. Heart: S1 and S2 within normal limits; no S3/S4 or murmurs, normal rate and rhythm. Are any further assessments or interventions required? In this case scenario, dehydration is one of the most serious immediate issues. Seek senior helpif the patient shows no signs of improvement or if you have any concerns. Catheterisethe patient to closelymonitor urine outputto guide fluid resuscitation and need for escalation. We combined both to indicate the continuity of the curriculum, and the building on prior knowledge. - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ We try to provide sufficient realism.. Keywords: diabetic ketoacidosis, simulation, expertise, emergency medicine Introduction Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus, most commonly occurring in patients with type I diabetes. It was developed for anesthesiology resident physicians with some background knowledge and experience caring for critically ill patients. opioids, sedatives, anxiolytics, insulin, oral hypoglycaemic medications). - Site 01:12 For diabetic assessment involving DKA, staging may include the use of a container with a small amount of acetone placed near the manikin because many students may not know what acetone smells like but will expect to smell something. Reprints: Koichiro Nandate, MD, PhD, Department of Anesthesiology, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, 500 University Drive Box 850, Hershey, PA 17033 (e-mail: [emailprotected]). Twitter: http://www.twitter.com/geekymedics Each PBL case typically goes over 23 days, affording the students periods to find information for the case. Diabetic Ketoacidosis: An Emergency Medicine Simulation Scenario A well-staged environment allows for greater student buy-in. She began experiencing progressively worsening thirst, increased appetite, and excessively increased urination. Collectblood testsafter cannulating the patient including: An ECG should be performed to screen for cardiac pathology such as arrhythmias which may be precipitated by electrolyte abnormalities (e.g. This is particularly important for core cases and low-frequency, high-stakes procedures and encounters. This is a 25-year-old woman with a medical history of diabetes medicated with 40 units insulin per day. This is particularly important for core . The authors of the second study reported that poor sleep quality (60% of respondents) and extreme fatigue (55% of respondents) are independently associated with safety risks on the job. If an obstruction is visible within the airway, use afingersweeporsuctionto remove it. You can plot as many parameters as you want and can choose to display either Historical data or have the graphs update as often as new data comes in and view them in Real-time. We ask the trainee why the blood pressure is so low or heart rate is so high, and how we should treat it. Recognize the signs and symptoms of a patient presenting with diabetic ketoacidosis. The facilitator guides the group only when necessary. One of the key differences with the immersive simulation is that the instructor is absent from the simulation environment. After initial insulin therapy has reduced plasma blood glucose levels (e.g. Abstract Introduction: This simulation on diabetic ketoacidosis (DKA) in the obstetric population presents learners with one of the more commonly encountered etiologies of critical illness in the pregnant patient. Calculate the patients current fluid balance using their fluid balance chart (e.g. Scenario in a Nutshell Diabetic ketoacidosis (DKA) in pregnancy. . Trainee will describe the changes in vital signs, the major metabolic, fluid, and electrolyte. Performing an ECG should not delay the emergency management of DKA. Physician working in the emergency department. At the end of the previous section, the trainee can make the diagnosis of DKA but has not confirmed it yet. Similar to a ward round, where the instructor would say: Come and listen to this patient with an aortic stenosis. www.cdc.gov/diabetes/statistics/prev/national/. In this section, we have to guide them as to what they should do first for the patient in this critical condition (ie, treat the A, B, Cs of airway, breathing, and circulation) before we can confirm the diagnosis. Experience has shown that the more experienced the provider, the more detailed the environmental and manikin staging should be, because providers are trained to take in and interpret visual cues as indicators of patient status. Competency-based medical education has seen widespread adoption in the field along with ongoing work in the areas of . However, this leads to confusion. Instagram: https://instagram.com/geekymedics Over the years, some groups happened to have the simulation session before the completion of the theoretical PBL session. (1) The assessment of a diabetic patient is best taught as a. Management of diabetic ketoacidosis in adults. Download: http://teamworkmatters.ocbmedia.com/media/DKA-Simulation-Scenario.docx Categories: 5th Year MBChB paeds scenario, Emergency Department, Human Factors, Interprofessional / multidisciplinary, Non-technical skills, Paediatrics, Postgraduate / newly qualified, Undergraduate / pre-registration Rating The instructors have to appreciate that the trainees participating in this simulation have not seen a diabetic patient in either a ward or ER, but that they have knowledge of the underlying physiology. A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. Using the arterial line, the scenario becomes much more dynamic. confusion, coma), All critically unwell patients should have. A chest X-ray should not delay the emergency management of DKA. You may search for similar articles that contain these same keywords or you may insulin-dependent type 2 diabetes), Altered consciousness (e.g. The choice of fluid type, rate of administration and volume should be tailored to the individual patient based upon their vital signs and electrolytes. . In the simulated environment, trainees will ask questions on how to interpret the data that they observe on the monitors and interpretation of clinical signs and symptoms on the manikin. Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. They have had no clinical exposure or any clinical experience. Make sure to re-assess the patient after any intervention. Assess the patients level of consciousness using the AVPU scale: If a more detailed assessment of the patients level of consciousness is required, use the Glasgow Coma Scale (GCS). Simulation Scenario for Anesthesia Providers Clark Obr, MD*, Anthony Mueller, MD . Given 6 to 8 back-to-back sessions, it is critical that every session starts and ends on time! You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate. Her medical, social, and family histories are not clear at the time of admission to the emergency department. By joining Cureus, you agree to our In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input. Often, the learner group will be unaware of these behaviors, but the instructor can key into the first few comments made during the transition between rooms. Refer to your local guidelines for further details. x]o ]?9kgq~:)?hE )R6!up}\<8||\]}Y~;xp~yQ$#4~djX&{n_m-]^K1/~/AD Hv 99evs,;8}8zwnhFxV.kf-V^? <> Diabetic ketoacidosis; Simulation training; Medical students. The consequences (low blood pressure, high heart rate, central nervous system status, etc.) The instructors role is to facilitate active learning through a combination of learning styles. Clearly communicate how often would you like the patients observations relayed to you by other staff members. Makeup may be used to depict gender, hollow eyes and cheeks, produce pallor or display bruises and scars. Stage 2: Emergency management of DKA and consideration of abnormal CTG. A patient presenting with altered level of consciousness and a blood sugar level below 80 mg/dL should be considered hypoglycemic, and treatment modalities should be consistent with those for a diabetic patient. Groups of more than seven may struggle with meeting objectives due to insufficient functional rolls. Extremities: mild cyanosis, no clubbing or edema (verbalized by instructors); pulses equal, and symmetrical (elucidated by trainees). Revisit history taking to explore relevant medical history and identify any precipitating factors for DKA. Emergency medical services workLife characteristics contribute to clinically significant excessive daytime sleepiness. See ourdocumentation guidesfor more details. Introduction: Diabetic ketoacidosis (DKA) is a life-threatening illness which classically presents with polyuria, polydipsia, and polyphagia that can rapidly progress to severe dehydration and altered mental status from cerebral edema. "Never doubt that a small group of thoughtful, committed citizens can change the world. An arterial blood gas (ABG) can provide lots of useful information to guide management including: A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. The Theory Urinary tract infections are a common DKA precipitant. Highlight selected keywords in the article text. From the Department of Anesthesiology, Pennsylvania State University College of Medicine, Hershey, PA. Dr. Murray is on the Speakers Bureau of METI, Sarasota, FL. Works with Traffic 2005, but . Please write a single word answer in lowercase (this is an anti-spam measure). - PSA Question Pack: https://geekymedics.com/psa-question-bank/ The learning environment should closely mimic real-world applications. She tends to drink sugar containing fluids (soda) when she is thirsty, and she eats fast foods (cream-filled muffins) when she is hungry. Manikin staging can provide strong cues. Abdomen: The abdominal examination reveals diffuse mild epigastric tenderness to deep palpitation but neither rebound tenderness nor guarding (result of examination given by patient or by instructor). Typically potassium levels should be maintained between 4.0 5.5 mmol/L and close monitoring is required. If you'd like to support us and get something great in return, check out our awesome products: You don't need to tell us which article this feedback relates to, as we automatically capture that information for you. As this is a PBL session, the trainees are not given any references. PBL in our institution is implemented as a small group (n 68 students) self study session with a facilitator, who incrementally discloses further information about the patient. 4. Tilt the forehead back whilst lifting the chin forwards to extend the neck. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. your express consent. (1), The assessment of a diabetic patient is best taught as a case-based simulation. Therefore, the session is divided into four sections of 15 minutes each, so that the facilitator is constantly aware of being on time (or not), even after the first 15 minutes period. The files are given in full in the web supplement (Appendix B, Supplemental Digital Content 2, https://links.lww.com/SIH/A2). The Theory to below 12 mmol/L) an infusion containing normal saline and 5% dextrose is typically commenced to prevent the development of hypoglycaemia, whilst allowing insulin therapy to continue to suppress ketogenesis and reduce serum electrolyte concentrations. The simulation experience serves to give substance to the theoretical words and concepts that the students encountered during the PBL sessions. Vital Signs: BP, 90/30 mm Hg (ECG shows normal sinus rhythm); central venous pressure, 0 to 2 cm H. Lungs: All lung fields are clear to auscultation without wheeze or rhonchi, and the respiratory pattern is typical of Kussmaul breathing, ie, large deep tidal volumes and increased respiratory rate. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction. The instructors never expect the trainees to exhibit full understanding of pathophysiology and skills in the treatment but do give them a few important points to understand the diagnosis and initial treatment of the patients with DKA. Circulating nurse in the emergency room (ER). Many of the preclinical students have never seen a real life clinical monitor or even an intravenous (IV) setup. - Timing 03:23 Initially, we required the students to write down the vital signs. Prehosp Emerg Care. Depending on scenario complexity, team dynamic and treatment modalities, this simulation may take 1020 minutes. - Exacerbating & relieving factors 05:12 Prehosp Emerg Care. Your message has been successfully sent to your colleague. If you have any scenarios you would be willing to share with the simulation community, please forward them to me. angioedema, rash) commence appropriate treatment as discussed in ouranaphylaxis guide. The required potassium replacement varies greatly. The immersive simulation is performed when the instructor feels comfortable with the acquired knowledge and skill base presented in the animated lecture or when the student group has sufficient practical experience to apply the cognitive, behavioral and technical skills outlined in the case scenario. This simulation session therefore aims to make the case come alive, and show this known case in a clinical context. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible. 2) Complete the assigned suggested readings 3) Complete the presimulation preparation virtual simulation game (Instructor will provide link) 4) Once you have completed reading this document and prepared for your simulation, please: a. Introduceyourselfto thepatientincluding yournameandrole. Does the patient need a referral toHDU/ICU? Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. endobj Simulation provides a safe environment where learning is enhanced through the deliberate practice of skills and controlled management of a variety of clinical encounters. Trainee will improve their understanding of clinical practice through reflective assessment of actual cases during the prior PBL sessions. She was taken to the Emergency Department from her soccer game because she complained of nausea, extreme fatigue, mild disorientation, and blurred vision toward the end of the soccer match. SimMan offers you the ability to provide simulation education to challenge and test your students clinical and decision-making skills during realistic patient care scenarios. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. Check out our NEW & IMPROVED quiz platform at geekyquiz.com, To be the first to know about our latest videos, subscribe to our YouTube channel . Surgical dressings and imitation blood can support medical history. The simulation session is also hosted as an interactive session. - Examples 05:45 Conclusion Several environments may be suitable for your classroom. We demonstrate to the trainees the significant changes on the monitors by asking them to point out any changes on the simulator (clinical examination) and the vital signs (monitor parameters). Simulation provides a safe environment where learning is enhanced through the deliberate practice of skills and controlled management of a variety of clinical encounters. Diabetic Ketoacidosis (DKA) Clinical Pathway Emergency Department | Children's Hospital of Philadelphia oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts. 2017 May 29;9(5):e1286. This video demonstrates how to use the SOCRATES acronym when taking a history of pain or other symptoms. Another example: At one minute into the scenario, the patient becomes unresponsive and their breathing becomes shallow. - Geeky Medics OSCE App: https://geekymedics.com/geeky-medics-app/ In the context of DKA, a patients consciousness level may be reduced. Case-based education adds a real-world aspect to the learning environment. Consider active re-warming techniques in patients with severe hypothermia. - Onset 01:48 There are several causes of DKA, which we remember by the "five I's". Should any changes be made to the current management of their underlying condition(s)? Interactive lecture/discussion with use of monitors that show the vital signs of the simulated patient on manikin. 1-6. 4. We have 18 to 20 PBL groups for an hour each in the week after their PBL DKA session. Note that if-thens must also include negative patient outcomes for when the provider doesnt take appropriate action. She had developed nausea, extreme fatigue, mild disorientation, and blurred vision toward the end of the soccer match. Review the patients drug chart for medications which may cause a reduced level of consciousness (e.g. DKA can develop within 24 hours and is potentially life threatening, requiring prompt recognition and therapeutic intervention. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned. 3. Medical simulation technology is a powerful tool for training physicians but papers dealing with DKA simulators are scarce. It may be necessary toexposethe patient during your assessment: remember to prioritise patient dignity and conservation of body heat. We also show them IV bags containing saline and Ringers lactate, as well as show them IV infusion sets. Much time was wasted explaining why it did not matter. Research Watch Box:Sleep, Fatigue & SafetyBy David Page, MS, NREMT-P 2. Please enable scripts and reload this page. After the initial treatment is initiated, by showing a simulated urine and blood, and by getting them to smell ketones, we can enable the trainee to confirm the diagnosis of DKA. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patients airway by looking, listening and feeling for signs of breathing. Target Learner Groups We do have a wig that we place on the patient, but we do not try for full realism. For instance, if we mimicked the noise and traffic of a real emergency department, this would constitute excessive realism, and become a distraction to beginner medical students. Both external and internal potassium balances are disturbed during the development and treatment of DKA. Please note that by doing so you agree to be added to our monthly email newsletter distribution list. An animated lecture may be described as a pseudo-simulation environment. However, we should not spend too much time on (not become distracted with) explaining unfamiliar monitors for the present trainees, such as central venous pressure or ETCO2 concentration. Blood sugar issues in the Type II diabetic will have a gradual onset, with diagnosis generally resulting from routine laboratory exams.(1). 3 0 obj Join the Geeky Medics community: The file explaining the session is sent to instructors 1 week before the sessions. Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult. 1 Potassium losses occurring both before and during treatment of DKA must be replaced. It involves a facilitating instructor, a small learner group and conceptual aspects of environmental and manikin staging to provide sensory cues. We introduce the Simulation Laboratory and the Simulator, and demonstrate: pulses, eyes blinking, pupil constriction, gas moves in and out of mouth (place hand over mouth), chest moves up and down. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. MassBay EMS Program Integrates Training for Dogs, Heat Waves Are Killing More LA Homeless People. Indeed, it is the only thing that ever has.". The main purpose of the simulation is to draw a line from the theoretical, boring biochemistry to the clinical manifestations. 3. An oxygen mask is also demonstrated as an alternative device, as these early trainees had mostly not yet seen any of these devices. ABG, venepuncture). Standardized patient as the voice of the simulator (or the simulation operator may play this role). Causes: Any situation arising in a diabetic that requires increased insulin without that demand being met can result in DKA. The teaching of diabetic assessment and management, like many other medical emergencies, lends itself well to case-based simulation. The students mentioned that they did not obtain the maximum value from the simulation session under these circumstances. Instructors should write a case study for the simulation before the session. The faculty member/course coordinator of Simulation Design Glycosuria leads to urinary losses of potassium through osmotic diuresis. We found it more important to have the students full attention so that they could concentrate on concepts and not on menial tasks such as recording data. Categories: Emergency Medicine, Medical Education Keywords: diabetic ketoacidosis, simulation, expertise, emergency medicine . Trainee will recognize and interpret the clinical signs and symptoms and the typical history of a patient with DKA, as well as understand the major causative factors of DKA. Data Description All the product records are stored at /user/spark/dataset/retail_db/products All the category records are stored at /user/spark/dataset /ret. Clinical Simulation in Nursing, Volume 39, 2020, pp. Simulation-based medical education: An ethical imperative. type 1 diabetes), Complete insulin insensitivity (e.g. Intubation lubricants can mimic drooling. Facilitator to ask how often to measure BMs We give the history of the patient to the trainees. The relationship between sleep, fatigue and patient and provider safety. One advantage to the animated lecture style is the ability to introduce treatment options in a methodically guided approach thats in conjunction with simultaneous environmental stimulus. Properly interpret a venous blood gas (VBG) and basic metabolic panel in a patient presenting with diabetic ketoacidosis. Questionswhich may need to be considered include: The next team of doctors on shift should bemade awareof any patient in their department who hasrecently deteriorated. A simulation training session is described designed to acquaint emergency medicine residents with the presentation and management of diabetic ketoacidosis through the use of simulation. DO NOT perform any examination or procedure on patients based purely on the content of these videos. Nandate, Koichiro MD, PhD; Abola, Ramon MD; Murray, W Bosseau MB; Whitfield, Carol PhD; Lang, Charles PhD; Sinz, Elizabeth MD. Its best, however, to allow the student group to continue so theyre able to evaluate their decision-making processes during debriefing. unilateral coarse crackles may be present if the patient has pneumonia which may have been the precipitant for DKA). A collection of surgery revision notes covering key surgical topics. We have spent many hours debating whether the small group format was a waste of time. See ourhistory taking guidesfor more details. Initially, we had a white board available, but the temptation (and habits) were just too strong, and the simulator sessions tended to become one way lectures, rather than an interactive, 2 way discussion.. Measure the patients capillary blood glucose and ketone levels to confirm the diagnosis and guide the management of DKA. Invasive monitors, including a left radial intraarterial and a right subclavian IV catheter, were placed. <>>> - Introduction 00:00 Keywords: diabetic ketoacidosis, simulation, expertise, emergency medicine Introduction Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus, most . I assigned true to life parking codes, and added some extra parking for the superfluous US Express AI. Scenarios. Some manikin models support a variety of human functions, such as capillary and facial cyanosis, facial sweating, foley catheter and IV placement, blood pressure generation, cardiac rhythms and abnormalities, defibrillation, cardioversion, external pacing and vital sign generation. In the final 10 minutes, we show how the patient has a good recovery after fluid replacement. 2011;15:108109. 2 0 obj Review the patientsoxygen saturation(SpO2): Auscultate the chest to screen for evidence of respiratory pathology (e.g. Capillary refill timemay be prolonged if the patient is hypovolaemic. Immersive Simulations Medical Simulation Scenarios are text documents outlining the various details of a simulation - everything from patient simulator settings to debriefing notes.Below is a collection of donated scenarios for you to use or modify. However, this turned out to be too slow, took too much time, and could not continuously demonstrate the direction of changes. Example: If the provider immediately evaluates blood glucose, then the reading will display 45 mg/dL. After entering the environment, the student doesnt have the option of leaving the simulation until the learning objectives and performance measures are achieved. To read Pages full Research Review column, visit www.jems.com/patient-care. These are not learning objectives in this program. In the meantime, you should re-assess and maintain the patients airway. DONT FORGET these 3 key components of the cardiovascular exam for your upcoming OSCEs Save this video to watch later and dont forget to follow Geeky Medics! and Available if the trainee asks: arterial blood gas, glucose, electrolytes, BUN and plasma osmolality (please see last section of Appendix B, Supplemental Digital Content 2, https://links.lww.com/SIH/A2, for values). We guide the group to suggest fluid. type 1 diabetes) Complete insulin insensitivity (e.g. See Table 4 for a suggested standardized script. vD0 x@FFJ{m[ 3//Oh|JR7! VbQuX#R M21 TheABCDEapproach can be used to perform a systematic assessment of a critically unwell patient. Conclusions This technical report describes the design and implementation of a simulation scenario on DKA for emergency medicine trainees. This style also doesnt mimic an actual scene, and a student may feel that treatment modalities and skills are performed at a slower rate than real-world applications. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration. An integral part of a PBL session is for trainees to be able to navigate through huge literature bases. 6. Each performance measure is separated into cognitive, behavioral or technical categories. Insert at least onewide-bore intravenous cannula(14G or 16G) and take blood tests as discussed below. They have had no clinical exposure or any clinical experience. YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LjMxakdNallNcng0, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkJPVjVZMzBKczY4, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkxEM2VkQzB2NTBr, Start typing to see results or hit ESC to close, Deep Vein Thrombosis (DVT) Examination OSCE Guide, Pre-hospital Advanced Life Support (ALS) OSCE Guide, Adult Choking (Basic Life Support) OSCE Guide, Paediatric Intravenous Cannulation OSCE Guide, Intrauterine System (Mirena) Counselling OSCE guide, Geeky Medics OSCE Book | Clinical Examination, Paediatric Gastro-oesophageal Reflux Disease, A Career as a GP with Special Interest with Dr Fiona Mosgrove, Absolute insulin deficiency (e.g. Weight, Height: Not given, normal appearing (as per simulator) but has lost 20 lbs recently. Other details are also important, including descriptions regarding patient language skill, social history, socioeconomic history, family history, religious practices or beliefs pertinent to treatment, and descriptive signs and symptoms. DO NOT perform any examination or procedure on patients based purely on the content of these videos. Virtual patient simulation (VPS) is an interactive computer simulation that recreates real-world scenarios with the objectives of training, education, and assessment for health care providers [].Virtual simulation has been used extensively to adapt nursing education to the COVID-19 pandemic context [], such as social distancing and/or confinement. You could also ask a student to smear a small amount of acetone on a piece of glass to see how volatile it is, helping them understand why its being exhaled by the DKA patient. Marx JA, Hockberger RS, Walls RM. The instructor should have visual access via one-way windows or cameras. As individuals with uncontrolled type I . Could we not just do this as a large group session to all 160 students (versus 20 1-hour sessions to groups of eight students)? The researchers found that long shift hours (24hrs), working overtime and marital/relationship stress were strongly correlated. Because of this consciousness status, it is very difficult to obtain information of cardiovascular, pulmonary, renal, hepatic, endocrine, hematology, or coagulation status other than uncontrolled diabetes. The optimal number of simulation participants is four to seven individuals, depending on the case study objectives.