Cognitive load theory and its applications in emergency medicine education

Throughout my medical education thus far, I have been very drawn to simulation and cognitive load research related to emergency medicine. This has provided me with an appreciation for the applications of cognitive load theory to diverse areas within the specialty, including medical education.

What is cognitive load?

The cognitive load theory was developed in the late 1980s and explores the ways in which the amount of mental effort affects your working memory, and subsequently, learning (1). Specifically, learning involves processing sensory stimuli through various forms of memory, until the stimuli are encoded into your long-term memory. When the working memory capacity is surpassed, the ability to acquire or learn new information can become limited and may lead to poor performance or errors. Since the development of this theory, research in this area has been expanding to enhance instructional design to optimize learning.

Fig. 1. The basic structure of memory, extending from sensory input to encoding of long-term memory (obtained from Mancinetti et al. (2019)) - (2)

Objective and subjective measures of cognitive load

Global collaborative and independent research initiatives have identified an array of objective physiologic measures (e.g. pupillometry, heart rate, galvanic skin response and EEG parameters), subjective psychometric measures (e.g. Paas, NASA Task Load Index (NASA-TLX)) and secondary task measures that are indicative of an individual’s cognitive load (3). Current research has been investigating the validity of these physiologic metrics beyond a controlled laboratory setting, in order to determine accurate measures that can be applied within dynamic and real-life settings. This can potentially allow us to monitor learners’ cognitive load in real-time and adjust teaching strategies accordingly to optimize learning.

Fig. 2. NASA-TLX cognitive load scale (obtained from Shively, J, NASA-Ames Research Center (2016)) and the Paas rating scale (obtained from Paas et al. (2008)) - (4-5)

Applications of cognitive load theory to emergency medicine education

A paper by Croskerry (2014) highlighted various factors that can influence cognitive load in the emergency department setting and lead to clinical errors, including overcrowding, and fatigue and circadian dyssynchronization secondary to shiftwork (6). Of relevance, a previous post on emDocs explored numerous strategies for emergency providers to mitigate some of this cognitive load (link here: http://www.emdocs.net/cognitiveload/). Furthermore, experienced emergency physicians have developed strategies to better manage their cognitive resources, effectively reducing their cognitive load relative to trainees in similar clinical scenarios. Therefore, there are many ways in which cognitive load theory can be implicated in emergency medicine and used to not only enhance the functional and spatial design of the emergency department, but to also optimize simulation training and other areas of learning for emergency medicine trainees. For example, Johannessen et al. (2019) evaluated the association between physiologic measures and the Paas scale in trauma team leaders using wearable technology during the resuscitation response, in order to better understand cognitive load expression in emergency physicians during traumas (7). Additionally, another study used galvanic skin response, heart rate and a modified Paas scale to assess the “Beat the Stress Fool” protocol in reducing mental effort during clinical simulation (7). Fraser et al. (2018) investigated the link between the cognitive load theory and debriefing simulations. Specifically, they evaluated whether the categorization of mental loads during debriefing can improve learning of this vital and complex skill, and they additionally discussed strategies to alleviate some of the associated cognitive load (8).  

Overall, cognitive load is an exciting and evolving area in research and has many diverse applications in emergency medicine and medical education as a whole. 

References and Further Reading

  1. Sweller, J. (1988). Cognitive Load During Problem Solving: Effects on Learning. Cognitive Science, 12, 257-285.
  2. Mancinetti, M., Guttormsen, S., Berendonk, C. (2019). Cognitive load in internal medicine: What every clinical teacher should know about cognitive load theory. European Journal of Internal Medicine, 60, 4-8. 
  3. Paas, Fred, et al. (2003). Cognitive Load Measurement as a Means to Advance Cognitive Load Theory. Educational Psychologist, 38(1), 63–71.
  4. Shively, J, NASA-Ames Research Center. (2016). Workload Measurement in Human Autonomy Teaming: How and Why? National Aeronautics and Space Administration. Accessed May 2020 at https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20160008388.pdf
  5. Paas, F., Ayres, P., Pachman, M. (2008). Assessment of cognitive load in multimedia learning therory, methods and applications. Recent Innovations in Educational Technology that Facilitate Student Learning, Chapter 2, pg.11-35. 
  6. Croskerry, P. (2014). ED cognition: any decision by anyone at any time. CJEM, 16(1), 13-9.
  7. Johannessen, E., Szulewski, A., Radulovic, N., Gilic, F., Braund, H., Wu, K., White, M., Rodenburg, D., Howes, D., Davies, C. (2019). Measuring cognitive load in a clinical setting: Medical learning and practice. (M.A.Sc thesis), Queen’s University, Kingston, Canada. 
  8. Fraser, K.L. et al. (2018). Cognitive Load Theory for debriefing simulations: implications for faculty development. Advances in Simulation, 3, 1-8.
Cite this article as: Nada Radulovic, Canada, "Cognitive load theory and its applications in emergency medicine education," in International Emergency Medicine Education Project, August 23, 2021, https://iem-student.org/2021/08/23/cognitive-load-theory/, date accessed: September 30, 2022

SAFE-BBOP! – A mnemonic for anaphylaxis management in the emergency department

anaphylaxis

While recently experiencing eight incredible weeks of Emergency Medicine rotations, I was reviewing my approach to anaphylaxis. Coincidentally, there was a real case a few days later, and I found the following mnemonic useful. If you’re having trouble remembering the different components of management for adult cases of anaphylaxis in the emergency department, think of SAFE-BBOP

This is not the exact order in which anaphylaxis should be approached, but it may facilitate memorizing commonly-used treatment modalities while learning and reviewing the general approach. The ABC algorithm should be applied first (see: https://iem-student.org/abc-approach-critically-ill/). Following the diagnosis of anaphylaxis, epinephrine should be administered promptly, as delayed administration has been associated with increased mortality (1-4).

SAFE BBOP

S - Steroids

Prednisone 50mg PO or methylprednisolone 125mg IV. Glucocorticoids are theoretically used to prevent a possible biphasic reaction; however, there is limited evidence for this.

A - Antihistamines (H1 and H2)

Ranitidine 150mg PO/50mg IV, Diphenhydramine 25-50mg PO/IV. Their use is based on studies of urticaria and should only be used as an adjunct therapy.

F - Fluids

Normal saline or Ringer’s lactate 1-2 L IV.

B - Beta-blocked

If a patient is on a beta-blocker and is refractory to the administered epinephrine, consider glucagon 1-5mg slow IV bolus over 5mins, followed by an infusion at 5-15mcg/min, titrated to effect.

B - Bronchodilators

For persistent bronchospasm despite epinephrine, an inhaled bronchodilator can be considered, such as salbutamol 2.5-5mg nebulized or 4-8 puffs by MDI with spacer q20 mins x 3. This is based on studies of acute asthma exacerbation and should only be used as an adjunct therapy.

O - Oxygen

Every patient, who is critically ill, requires supportive oxygen treatment.

P - Positioning

Recumbent position with lower extremity elevation (consider left lateral decubitus position for pregnant patients to prevent inferior vena cava compression).

As for disposition considerations, the SAFE system below was introduced by Lieberman et al. (2007) to recognize the four basic actions to address with patients prior to discharge from the emergency department (5).

  • Seek support
  • Allergen identification and avoidance
  • Follow-up for specialty care
  • Epinephrine for emergencies

For a detailed review of anaphylaxis definitions, signs and symptoms, refer to this great Life in the Fast Lane article: https://litfl.com/anaphylaxis/

References

  1. Prince, B.T., Mikhail, I., & Stukus, D.R. (2018). Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. J Asthma Allergy, 11, 143-151.
  2. Sheikh, A., Shehata, Y., Brown, S.G., & Simons, F.E. (2009). Adrenaline for the treatment of anaphylaxis: Cochrane systematic review. Allergy, 64(2), 204.
  3. Simons, F.E. (2008). Emergency treatment of anaphylaxis. BMJ, 336(7654), 1141.
  4. McLean-Tooke, A.P., Bethune, C.A., Fay, A.C., & Spickett, G.P. (2003). Adrenaline in the treatment of anaphylaxis: what is the evidence? BMJ, 327, 1332.
  5. Lieberman, P.,Decker, W., Camargo, C.A. Jr., Oconnor, R., Oppenheimer, J., & Simons, F.E. (2007). SAFE: a multidisciplinary approach to anaphylaxis education in the emergency department. Ann Allergy Asthma Immunol 98(6), 519-23. 
 

Further Reading

Cite this article as: Nada Radulovic, Canada, "SAFE-BBOP! – A mnemonic for anaphylaxis management in the emergency department," in International Emergency Medicine Education Project, December 11, 2019, https://iem-student.org/2019/12/11/a-mnemonic-for-anaphylaxis-management/, date accessed: September 30, 2022

Why Emergency Medicine? A medical student’s reflection

why emergency medicine - nada radulovic - canada

As the Canadian Resident Matching Service (CaRMS) application cycle approaches for the Class of 2020 in Canada, I have been reflecting on the common question of “Why Emergency Medicine (EM)?” This has encouraged me to consider all aspects of the specialty that I love, as well as some of the perceived challenges of pursuing EM residency training. Additionally, I have been asked about advice for medical students interested in exploring EM, mainly from those beginning medical school or clerkship this month. So, in an attempt at a personal reflection exercise, I am also hoping to provide some practical points for consideration for any medical student thinking about exploring this wonderful specialty.

Some of the reasons why I love Emergency Medicine:

1

Versatility

From the clinical presentations and various procedures, to the patients and team members working in the emergency department, I am constantly drawn to the multifaceted and dynamic nature of EM. Speaking to well-seasoned staff physicians, this versatility has them constantly learning and encountering new things. During my first EM shift of clerkship, the first patient of the day came in with atrial fibrillation, the second was hypothermic and without vital signs, the third had lower back pain, and the fourth presented with a COPD exacerbation. The range in presentations and levels of acuity are something that greatly appeal to me and allow for constant growth in Medicine. This diversity provides endless opportunities to learn new things in the setting of, at times, very limited information and time.

Versatility

2

Opportunities for subspecialization

EM offers several formal opportunities to find your niche within the specialty, in the form of fellowships. These areas include ultrasound, trauma, resuscitation and reanimation, critical care, toxicology, pediatric EM, disaster medicine, and medical education. This is not an exhaustive list and will vary depending on where you are training. The Canadian Association of Emergency Physicians has developed an accessible directory for enhanced competencies: https://caep.ca/em-community/resident-section/enhanced-competency-directory/

Subspecialization

3

Portability

One long-standing interest of mine throughout my post-secondary education has been Population and Global Health. Therefore, something that I really appreciate about EM is its portability. EM is present in an array of settings, from rural to large academic centers. This flexibility allows you to tailor your practice to your interests, both within and outside of Medicine. In a recent post by one of iEM’s blog authors, Dr. Ibrahim Sarbay, 82 countries were identified as recognizing EM as a primary specialty. See “Countries Recognize Emergency Medicine as a Specialty” for a breakdown of countries: https://iem-student.org/2019/05/13/countries-recognize-emergency-medicine/)

Portability

4

Working with vulnerable populations

This is something that continues to draw me to EM, as the emergency department serves as an entry point into the healthcare system for some individuals. Throughout my rotations, I have been privileged to work with various patients, and have found myself constantly inspired from learning about their unique challenges within the healthcare system, as well as the various interventions that have been developed to target social determinants of health at institutional and systemic levels. While there is considerable work that still needs to be done to address these disparities, I continue being fascinated with the various advancements that are underway. This has additionally expanded my understanding of humanity and has forced me to reflect on how I approach clinical interactions. Overall, it has allowed for considerable growth within Medicine and on a personal level. This continues to be one of the aspects of EM that I truly value most. 

Vulnerable Populations

Perceived challenges

I need to preface this by saying that it may be difficult to truly appreciate challenges of any specialty from solely experiencing it through the role of a medical student. However, these are points that I consider challenges of EM-based on my personal experiences during several EM rotations, as well as through discussion with residents and staff physicians.

1

Physician burnout

A recent study in JAMA by Dyrbye et al. (2018) surveyed second-year resident physicians in the United States. Their findings indicated a burnout prevalence (based on the Maslach Burnout Inventory) of 53.8% of surveyed EM residents. While EM did not exhibit the highest burnout rate (Urology, 63.8%; Neurology, 61.6%; Ophthalmology, 55.8%), it was on the higher end for specialties that were assessed. [1] The topics of burnout and wellness promotion have become fairly pronounced in the EM community. EM Cases released an episode in 2017 regarding burnout prevention and wellness during EM training, that featured Dr. Sara Gray and Chris Trevelyan. Link: https://emergencymedicinecases.com/preventing-burnout-promoting-wellness-emergency-medicine/

2

Practicing “fishbowl medicine”

I have heard this term thrown around quite a bit, alluding to the fact that specialties are observing the way that EM physicians are managing patients. The fishbowl effect reflects the tendency of a specialist in other disciplines to compare the actions of EM physicians to the standards of practice that are held in the setting of those specialists (e.g., the operating room, the specialty clinics, etc.). [2] While I recognize that this can occasionally cause conflict between groups, I personally love the multidisciplinary nature of EM and view the collaborative efforts with other specialties as further opportunities for growth regarding my understanding of various disease processes and overall management of patients. Dr. Sheldon Jacobson published an interesting reflection of how this concept can actually be viewed positively within the practice of EM [2]. 

Fishbowl

Everyone has personal reasons for pursuing any specialty, and for many, the reasons for pursuing EM run deeper than those listed above. However, these are just some of the factors that I believe to be basic and practical considerations for this specialty. EM makes me excited to expand upon my knowledge base in Medicine, to constantly learn and better my understanding of the human condition, and to be a part of the supportive environment that multidisciplinary EM teams create. It is an ever-expanding field and I hope to one day be able to contribute to it in a meaningful way. I could go on and on about why I love the specialty, well beyond the limits of a blog post – I may be a little biased, but EM is pretty great!

References and Further Reading

  1. Dyrbye LN, Burke SE, Hardeman RR et al. Association of Clinical Specialty with Symptoms of Burnout and Career Choice Regret Among US Resident Physicians. JAMA. 2018 Sep;320(11):1114-1130.
  2. Jacobson S. The Fishbowl Effect. Acad Emerg Med, 2015 Oct;12(10):956-957.

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Cite this article as: Nada Radulovic, Canada, "Why Emergency Medicine? A medical student’s reflection," in International Emergency Medicine Education Project, August 30, 2019, https://iem-student.org/2019/08/30/why-emergency-medicine-a-medical-students-reflection/, date accessed: September 30, 2022

Point-of-Care Resources in the ED

Point-of-Care Resources in the ED

In the era of Free Open-Access Medical education, there are countless invaluable resources available for medical learners. Over the years, they have been designed and optimized for more portable use, with the possibility of serving as on-the-go resources for trainees. Having just completed my third year of medical school – and also, my first year of clerkship – I have discovered several point-of-care tools that have proven to be immensely useful in the emergency department (ED). 

Not only have they been wonderful for obtaining quick information and have helped guide my history-taking, physical examinations, differential diagnoses and management, but they have also helped me learn through repetition using the same sources of information.

The majority of these are available both online and as mobile applications, so they are very accessible in the ED setting when you have multiple patients on the go with a variety of concerns.​

Below are a few that I have found particularly helpful this past year. As always, these resources are designed purely as clinical aids and are not meant to replace clinical judgment.

For accessibility purposes, I have only included free resources; however, some do offer additional features that are available for purchase. I have no affiliation with any of these and am commenting solely on the basic features that are available.

QuickEM

by Sentral Clinical Research Services, LLC
Download: Google Play l Apple

QuickEM features a list of common adult and pediatric complaints, ranging from syncope to hematuria. For each presentation, it lists considerations for histories, physicals, differentials, investigations, treatments and disposition. There is also a tool which facilitates the calculation of various useful parameters, such as QTc and Well’s score for DVT and PE. One unique component of this application is that it provides clinical pearls at the end of each topic and allows you to make personalized notes for each presentation, which you can refer back to. Additionally, a list of references is provided for further review. Overall, QuickEM breaks down a broad range of presentations into essential components, and has served as a very useful and quick EM-specific resource.

MDCalc

by MD Aware, LLC
Download: Google Play l Apple
Website: https://www.mdcalc.com/

MDCalc can be used online or through a mobile application. It has a long list of formulae which can be sorted by specialty (unsurprisingly, there are quite a few for EM!). One really great feature is the “favorites” section, which allows you to add specific formulae to your folder for easier reference. Once you’ve done the calculation, there is also a section that addresses subsequent investigation and management steps, as well as an evidence section that highlights the associated studies behind the formula. Overall, not only has it helped me easily calculate parameters, but it has also expanded my knowledge base by addressing the reasoning behind commonly-used clinical measures.

Orthobullets

by LineageMedical Inc.
Download: Google Play l Apple
Website: https://www.orthobullets.com/

Orthobullets has been a staple resource throughout my Orthopedic Surgery block and then during my EM rotations for musculoskeletal-related presentations. It includes an extensive list of topics and outlines relevant anatomy, pathology, differential diagnosis, investigations and management, while also highlighting specific surgical techniques. Moreover, it includes a question bank, sample cases and educational videos, all of which are excellent for general MSK review. It can be downloaded onto your phone for easier, on-the-go use, but it does require you to register for an account (free) if you would like to access the additional features (cases, question bank, videos, etc.).

MediCode

by National Health Care Provide Solutions, LLC
Download: Google Play l Apple

I started using this mobile application as a quick review before going into the simulation lab during my EM rotations. It provides easy access to numerous ACLS, BLS and PALS algorithms that can be viewed as images or approached using an interactive step-by-step feature. There are also some embedded instructional videos to consolidate all of the content. Not only does this application allow you to flip through various algorithms fairly effortlessly, but it also lets you test your knowledge and identify areas for further review through multiple-choice questionnaires.

By no means is this an exhaustive list – there are so many wonderful resources out there that I have not mentioned and that I have yet to discover! These are just several that I have regularly used and that have come up repeatedly through discussion with my colleagues. What are some point-of-care resources that have been invaluable to your education and have been helpful throughout your rotations? We would love to hear about them!

Cite this article as: Nada Radulovic, Canada, "Point-of-Care Resources in the ED," in International Emergency Medicine Education Project, June 5, 2019, https://iem-student.org/2019/06/05/point-of-care-resources-in-the-ed/, date accessed: September 30, 2022