The Medical Emergency Simulation Olympics – G.SEM

the emergency medical simulation olympics

The use of realistic simulation on medical teaching is increasingly being used in the universities of Brasilia. The controlled environment training brings important benefits and develops the non-technical skills of participants. Therefore, the Congress of Medical Emergencies of the Federal District that took place this month in Brasilia, Brazil, promoted a realistic MEDICAL EMERGENCY SIMULATION OLYMPICS (literal translation: Gincana de Simulação em Emergências Médicas – G.SEM) with medical and nursing students. The participants felt tremendous satisfaction and acknowledgment of their own flaws that must be improved before they graduate.

However, what does realistic simulation mean? By definition, “it is the technique, not technology, for reproducing or amplifying real experiences by guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive way.” That is, we set up environments of low, medium or high complexities that mimic reality. This way, the participant can emerge in practice without putting the patient at risk.

Through Kolb’s experiential learning cycle, we can understand how learning occurs during simulation.

kolb learning cycle

During the simulation, the participant takes part in concrete experience, being able to identify knowledge gaps in which he can work. At the debriefing, the instructor helps the gamer to contemplate his performance.

When the participant gives meaning to what has happened, he becomes able to abstract and modify his mental model, which will be tested with active experimentation, generating a concrete reaction.

When simulating, not only theoretical knowledge is required, but also practical knowledge, such as how to do and how to act when facing the proposed situation. Doing this kind of exercise, we can better assimilate the content in a playful and effective way. Through error, and the reframing of debriefing, the participant can retain the content with the experience that will come across in the real environment.

The simulation was first used in the aerospace industry, where one mistake could cost many lives. Therefore, the practice of simulation in medicine is indispensable since we work directly with human lives. Train, train and train! This is the emergency mantra! Because by the time you are in the Emergency Department, acting, you already need to know what to do. The time to make mistakes is in the simulation. Moreover, it’s important to keep in mind that an error-free simulation is not a simulation, it is just a theater.

It is possible to divide this learning method into some levels. Through Miller Pyramid, we can analyze the clinical capacity in four levels: know, know-how, show-how, and does. Simulation is increasingly used to teach the first three levels, as it enables the programming of specific environments and conditions to the needs of each participant, promoting a favorable outcome.

Is it like playing pretend? Yes. The simulation can be compared to a pretend play. We can’t reproduce the exact reality, so we set up a fiction contract, where the instructor admits that the simulation is not real but tries to reproduce it as faithfully as possible, and the participants agree to act as they would in real situations.

Therefore, if during a high complexity simulation, a patient with low oxygen saturation needs intubation, for example, the participant must act by observing vital signs on the monitor, asking for drugs, infusing, ventilating, and intubating the doll and not just saying what he would do.

The Chiniara et al Simulation Zone Matrix, commonly used to demonstrate the teaching of simulation in pediatric emergencies, can be extended to emergencies in general. Simulation becomes advantageous over other teaching methods in low-opportunity, high-severity situations, quadrants where emergency is, due to low student exposure and increased concern for patient safety.

With simulation, it is possible to practice technical and non-technical skills, for example, interaction with the multidisciplinary team, leadership, communication and crisis management, which is almost impossible in a classroom.

When we promoted the G.SEM – Emergency Simulation Gymkhana – held by the EMIGs in Brasilia, we had many positive feedbacks from participants, and proved to be effective in exposing to participants points that they needed to improve to raise the level of their clinical practice.

Participating in G.SEM was a very exciting experience for me, as I was able to review important concepts and behaviors in various pathologies, including the approach to cardiopulmonary arrest. It was also a very interesting emotional experience, as we had a short time to make decisions since all patients had life-threatening pathologies that needed fast decisions and actions. In this context, an adrenaline over-discharge and, consequently, tachycardia were generated, generating significant stress that leads us to the real process of approaching a critically ill patient. In addition, one of the most important positive points was the team performance, as the team consisted of 2 medical and one nursing student, so we needed to work together, respect each other and make our communication were efficient and clear. Through the scenarios, it was possible to see how much we improve as a team, and in the final scenario, we were already much more intertwined and acting in a much more organized way compared to the first one. I also emphasize the importance of the evaluator’s feedback at the end of each season, as this allowed us to identify the errors and to correct them in the following simulations and, of course, to future. Finally, it was a unique opportunity that certainly made me grow very intellectually and also allowed me to improve the relationship with the team, which is indispensable in a multidisciplinary context.

says Lucas, a medical student who participated in the simulation scenarios.
Winners

There were six simultaneous scenarios, including two pre-hospital scenarios that were assembled by firefighters. G.SEM took place at the Uniceplac Realistic Simulation Center, with the support of the DF Fire Department, and the International Student Association of Emergency Medicine (ISAEM).

Content and Details

  • 4 multidisciplinary teams, each consists of 3 medical students and 1 senior nursing student.
  • 6 simultaneous scenarios. All teams exposed to all scenarios. 1) Diabetic ketoacidosis in children, 2) Intra-hospital care for multiple trauma patients, 3) Acute myocardial infarction, 4) Sepsis, 5) Pre-hospital care for multiple trauma patients (car x bicycle accident), 6) Pre-hospital care for cardiopulmonary arrest and the patient suffering from penetrating trauma.
  • Each scenario had a total duration of 20 minutes
  • Each scenario had a checklist of actions and knowledge that was expected from the team in that situation.
  • In the end of each simulation, the team went through a quick debriefing, for about 8 minutes, with the station instructors.
  • After all scenarios, there was a debriefing with the residents of emergency medicine, in order to demonstrate to participants the reality of those situations in the emergency department
  • The winning team was the one with the most checklist points.
  • The teams were awarded according to their classification.

The simulation itself already causes some anxiety in the participant, since it demonstrates its flaws and puts in check all its theoretical knowledge that should be applied in a practical way. During our emergency simulation game, we noticed an increased level of anxiety and stress from participants. It is believed that the necessity of quick decision making that the emergency requires and the short time of the season were determining factors. However, participants reported that the multidisciplinary team made the simulation environment different, that’s because nursing students do not have realistic simulations as a requirement in their course, and it’s not common the integration between the courses in a simulation scenario.

As a lesson of this event, we conclude that it is extremely important to integrate the programs in the undergraduate years, and we can use the simulations as a convergence point. It’s important to remember that the Emergency Department only works with a cohesive multidisciplinary team. One of the goals of G.SEM was to demonstrate to students this reality and break the barrier between programs by showing that the work in the Emergency Department is teamwork and that always needs team training!

References and Further Reading

  1. Gaba DM. The future vision of simulation in healthcare. Simul healthc 2007;  2(2): 126-35
  2. Cheng A, Duff J, Grant E, Kisson N, Grant VJ, Simulation in paediatrics: An educational revolution. Paediatri Child Health. 2007; 12(6): 465-8
  3. Kolb DA. Experiential learning: Experience as the souce of leatning and development.  Englewood Cliffs, NJ: Prentice-Hall; 1984
  4. Zigmont JJ, Kappus LJ, Sudikoff SN. Theoretical foundations of learning through simulation. Semin Perinatol. 2011; 35 (2): 47-51
  5. Paizin Filho A, Scarpelini S. Simulação: Definição: Medicina (ribeirao Preto). 2007; 40(2): 162-6
  6. Miller GE. The assessment of clinical skillscompetence/performance. Acad Med. 1990; 65 (9 Suppl): S63-7
  7. Couto TB. SImulação realistica no ensino de emergências pediátricas na graduação. São Paulo. 2014.

Reviewed by: Bruna Martins, Jule Santos and Henrique Herpich

Cite this article as: Rebeca Rios, "The Medical Emergency Simulation Olympics – G.SEM," in International Emergency Medicine Education Project, October 30, 2019, https://iem-student.org/2019/10/30/the-medical-emergency-simulation-olympics-g-sem/, date accessed: November 20, 2019

Macro-lensing the Emergency Department

Macro-lensing the Emergency Department

How do you remember the emergency department (ED) that trained you? Could it be that you have learned a lot more than just medicine there? Between worrying about the delayed laboratory report and explaining the need to rule out a myocardial injury to a visitor of a patient with peptic ulcer disease, you might have picked up other attributes. Subtle traits that have nudged your personality. Remembering the ED where I did my internship sparks nostalgia and makes me want to speed up my typing. As if I need to attend to something else right after this. Hopefully, I’ll give you a glimpse of what putting on different lenses can show even when we look at the same object.

Peeling yellow paint, some old cracks in the wall, and an acute sense of urgency lingering in the air are what I remember of the department. Patan Academy of Health Sciences has an ED where confused students scratching their heads to the witty professors’ question takes you to your own golden days. A subtle grin on the wise face of a grey-haired professor eagerly waiting for the next wrong answer makes you want to reach out to your old mentor. A know it all student on the verge of blurting out the answer physically holding himself behind makes you wonder what that one classmate of yours is doing these days. It is a place where teaching, helping people, running against time and having fun while at it, blends into an experience of a lifetime. Stories of eased pain, dodged suffering and narrow escapes from grave aliments enrich the history of the department.

One fine evening in the department as an intern I found myself seated in the doctor’s station, a rare but insightful experience. I found myself pondering about the lessons I can take from this part of the hospital: not just medical knowledge but lessons I can share with people from different facets of life. Below I list the common situations or sayings used in a typical ED and try to translate it for use in day to day life.

Think horses before zebras but watch out for zebras that can fly

A patient with mild fever, chest pain, and some respiratory distress probably has some sort of URTI. But the very fact that he/she landed up in the ED makes the doctor order an ECG because of the chest pain. The doctor will, of course, be leaning towards a more common diagnosis. Ruling out a diagnosis with grave prognosis, however, will be among the top priorities. 

searching zebra

This can translate into studying common exam materials while also being aware of the zebras. Zebras show up rarely, but when they do, they tend to be stubborn. Be aware of the topics that don’t usually show up in your exam but impact the outcome when they do. We can also borrow this idea while thinking about anything in general. We tend to assume the worst, but when your date is late to dinner, it probably is just the busy traffic.

Communication is the key

A medical officer reads the patient’s history to the professor using as few words as possible, pertinent negatives and a precise format. The information and condition of the patient are conveyed very accurately. When reporting history, we aim for effective communication at its best. 

communication

I wonder how many day-to-day problems can be solved if only we communicated that efficiently outside of history taking and reporting. Using clear words, very few fillers and addressing what we don’t mean beforehand can help in getting the intended message across.

Prioritizing

The most critical patients that visit Patan Hospital head for the ED. Recognizing them and treating the ones who need immediate attention is the second nature of a good emergency physician. Likewise, being able to focus on the most critical aspects of one’s life can be an attribute worth borrowing from the department. 

prioritising

How many times do we complain that we just do not have enough time to do things that are important to us? It’s mostly about deciding what comes first.

Resource allocation

This sort of ties into the previous one. Most experienced physician attends the most critical patient. More nurses are allocated to and the best USG machine is used in the red triage area. Time, money, physical or mental effort all are resources we use to get tasks done. Sometimes success differs from failure, not in how much effort is put but where it is used. Determining which task is most resource-intensive or most productive can be a worthwhile idea to learn from the ED.

resource allocation

Did you check your tools?

Monitor connected to a gradually stabilizing patient beeps rapidly, indicating a sudden collapse. As you run towards the patient with your ACLS neurons firing at a rate more rapid than the patient’s declining pulse, do take a look if the pulse oximeter is connected correctly. Translated in the world where things go south more frequently than not, decide if it is a perceived problem or a real one. How many times have you let yourself go into flight or fight mode only to realize that the threat wasn’t even there?

Give thiamine before glucose

Hypoglycemia kills. Glucose save lives. Even then, giving thiamine before glucose is the norm in most EDs. The biochemistry behind is simple; thiamine is a cofactor used by many enzymes in glucose metabolism and depleting more thiamine can cause Wernicke Korsakoff disease. Look at it with the lens of a student who needs to start preparing for an exam. Determine your thiamine (proper sleep, good food, exercise, enough water and probably mindfulness). Only then glucose supplementation (studying) will yield results.

The loudest screamer isn’t always suffering the most

“How do you triage when there are more people than you can attend to?” asked a professor. The answer was funny but made a point firmly. “You should ask the most critical patients to come forward. Then you attend those that are left behind!”. The idea being; sickest of them all won’t even be able to advocate for themselves. Similarly, we can be tactful when overwhelmed by problems. Try to come up with ideas to segregate the screamers (problems that seem to be the biggest) from the sickest (actual problems).

triage

Know your limits and ask for help

We manage acute exacerbation of COPD in the ED. Not all patients that feel relieved are discharged from there. Some patients require medical consultation and transfer. This, in no way, means that the ER physicians are incompetent in managing the disease throughout. Rather it is the evidence of understanding the job description and trust in the system as a whole. Asking for help when need be is critical to our wellbeing. Being able to ask for help shows courage and humility above all.

knowing limits
Cite this article as: Sajan Acharya, "Macro-lensing the Emergency Department," in International Emergency Medicine Education Project, October 28, 2019, https://iem-student.org/2019/10/28/macro-lensing-the-emergency-department/, date accessed: November 20, 2019

A becoming specialty – EM in Tanzania

We all pass through milestones of growth and every stage is a hurdle to the next, how we choose to view it is our own choosing. Imagine seeing it from a child’s perspective; a five-month-old wobbly reaching for a shiny new toy that seems just a grasp away, falls flat on his face cries then realises; ooh wait there is that shiny new toy again. Picks up from where he left off and with every advance sitting transforms to crawling.

Joshua Yonazi 2014
Currently doing her Paediatric Cardiology Fellowship

As a medical student, I had no exposure to Emergency Medicine as a specialty. We had an OPD that was functional 24 hours. Paediatrics was what I set my mind to do, and Dr. Stella Mongella, who remains a role model to date influenced a lot of what I am today in my timeliness and responsibilities. It was a see admire and try to become not her but myself in the best way I could. 

After completing my medical school, which is a five-year program, the next step was to go for my one-year internship training. I moved from a mostly public health facility to a private health facility. It was until 2014 when I was employed as a Resident Medical Officer at the Accidents and Emergency Department of the Aga Khan Hospital Dar es Salaam when I met Dr. Yash Dubal, an Emergency Physician who had just joined the hospital that same year. He had graduated from Muhimbili University of Health and Allied Sciences (MUHAS) and working with him is what made me realise what a becoming speciality Emergency Medicine is and in less than a year I decided to join the same residency program he had graduated from.

This three-year residency program is a core competency-based training in research, trauma, paediatric care, leadership skills, bedside ultrasound, recognition and treatment of toxicological, obstetric and medical emergencies. Offers elective exchange opportunities for residents to go abroad for observership as well as those from abroad coming to Tanzania. Muhimbili National Hospital first and the only hospital to date to have an Emergency Medicine Residency Program in Tanzania and first to have initiated an Undergraduate Emergency Medicine Rotation in 2014. Since the presence of this fully capacitated Emergency Medicine department, there has been great change in the delivery of services and outcome within the hospital and its graduates are part of regionalisation of emergency care in Tanzania.

To date there are nine health facilities with fully functional 24 hours emergency departments with Emergency Physicians available at; Muhimbili National Hospital, Bugando Medical Center, Kilimanjaro Christian Medical Center, Arusha Lutheran Medical Center, Mount Meru Hospital, Mbeya Zonal Referral Hospital, Bombo Hospital, Benjamin Mkapa Hospital and The Aga Khan Hospital. Development of EMS is in progress with basic ambulance providers, attendants and dispatch training complete.

Muhimbili National Hospital
Mbeya Zonal Referral Hospital
Benjamin Mkapa Hospital
Kilimanjaro Christian Medical Center
Emergency Medical Services
The Aga Khan Hospital Dar es salaam

Emergency Medicine is a Becoming Specialty with core values to safely deliver those critically ill and injured from the community to the acute care units for resuscitation, stabilization and transfer to specific units for definitive care.

Cite this article as: Kilalo Mjema, "A becoming specialty – EM in Tanzania," in International Emergency Medicine Education Project, June 24, 2019, https://iem-student.org/2019/06/24/a-becoming-specialty-em-in-tanzania/, date accessed: November 20, 2019