Home Made IV Access Ultrasound Phantoms

home made IV access ultrasound phantom

We recently had the 3rd Tanzanian Conference on Emergency Medicine. Point of Care Ultrasound (PoCUS) training was one of the pre-conference workshops. Ultrasound-guided intravenous cannulation can be very challenging for many doctors in the emergency department.

Therefore, we had a station providing a real-time opportunity to practice IV access using our homemade ultrasound phantoms. And I shall share with you how we came up with this solution.

Ingredients

  • A plastic container (dimensions used here 8 x 5.5 x 5inches)
  • Long balloons
  • Assorted food colors
  • Gelatin
  • Metamucil (psyllium)
  • Powdered household detergent
  • Spoon, sieve, hand mixer, measuring cup, cooking pot and cooker
  • Filler syringes
  • Gloves
Ingredients for making the mixture
Ingredients for making the mixture
Food coloring dye
Food coloring dye
Equipment for making vessels
Equipment for making vessels

How to make your mixture

Take a cooking pot and fill it with 1200 mls of water (we used this as our molding device could accommodate this amount of mls) bring it to a boil (just as it begins to form tiny bubbles on the base add gelatin powder 8 tablespoons and stir with a hand mixer until it completely dissolves. Thereby add 2 tablespoons of Metamucil and 1 tablespoon of detergent and continue stirring with low flame until the mixture begins to thicken. At this point, you will also see foam that sits on top of the mix. Use a sieve to get the foam out. You can, at this point, add any colors that you would want. Let the mixture cool a little before pouring it into the container. As it cools, you will notice it becoming thicker.

How to set-up your mold/containers

You will need to make a hole on both ends on the container using a hand drill or a hot pointed knife. For this case, since we didn’t have a drill, we used a knife with a pointed tip – heated it up in a burner until it was hot enough and used it to make holes through the plastic container using a circular motion. It is important for the holes not to be too big but estimated to the caliber/ diameter of the long balloons since we need just enough space to pass the balloons across.

For our case, we made 4 holes, 2 on each end. But you can do more if you want. You can arrange balloons in superficial or deeper locations.

To setup the vessels using the long balloons, you will need half cup of water and red color dye. Mix just enough to make a mixture that looks like blood. This can be filled in the balloons with a syringe. Since the color dye can stain your fingers, it is important to use gloves just to prevent your fingers from staining.

Tip: To make an artery, you can fill the balloon much more so that there is minimal compressibility and for the vein, you can fill just enough and have room for compressibility. Don’t fill the balloons before passing it through the container; if you do this, the filled balloon won’t manage to fit into the holes. Once fixed, tie both ends to make knots that are big enough to cover the seal the holes made.
Before pouring the mixture into the container, spray it with some oil, or you can use a cloth dip it in oil and apply it on the inside of the container.

After that, pour your mixture in the container and let it cool. You can place it in the refrigerator and use it the next day. We left ours for 24 hrs prior use.

You can use silicone seals at the holes if you notice to have any leaks. Otherwise, if you don’t have this, you can use plastic food wrap to create a seal between the balloon knots and the container just so the mixture does not leak out until it has set.

Cooling in the refrigerator, note the plastic food wraps used as seal here and the knots
Cooling in the refrigerator, note the plastic food wraps used as seal here and the knots
6 hours after refrigeration
6 hours after refrigeration
Final product
Final product

And finally, the images that you will have on ultrasound.

Short axis/transvers view
Short axis/transvers view
Long/longitudinal axis view
Long/longitudinal axis view
TACEM - IV access workshop under US guidance
TACEM - IV access workshop under US guidance
Cite this article as: Masuma Ali Gulamhussein, "Home Made IV Access Ultrasound Phantoms," in International Emergency Medicine Education Project, November 18, 2019, https://iem-student.org/2019/11/18/home-made-iv-access-ultrasound-phantoms/, date accessed: November 20, 2019

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

How to make the most of your EM Clerkship

How to make the most of your EM Clerkship

Emergency Medicine has something for everyone!

Starting the Emergency Medicine (EM) Clerkship is one of the most exciting times of any medical student’s life, regardless of whichever specialty they plan on specializing in because EM has something for everyone. It is like solving all those questions that begin with ‘A patient presents to the Emergency Department with…’ but in reality, at a faster pace and with more tricky situations. This can make students feel overwhelmed, as they find themselves juggling between books and resources as to which one to follow or which topics to learn, and I am here for just that! To share the approach that helps many students get the hang of EM and make the most of their time in one of the best learning environments of any hospital.

Prepare a list of common conditions

The basic approach would be first to jot down all the problems you can think of.

Here is a list to help you get started: Core EM Clerkship Topics

There are problems that you may be heard a lot such as Chest Pain, Heart Failure, Shock (and it’s types), Acute Coronary Syndrome, Sepsis, Pulmonary edema, Respiratory Failure, Coma, Stroke, Hypoglycemia, Subarachnoid Hemorrhage, Fractures, Head Trauma, Status Epilepticus, Diabetic Ketoacidosis, and Anaphylaxis.

As every doctor you meet will always say, common is common, so always focus on things that you have heard and seen most about, read about them, make notes on their clinical features, differentials, investigations and management. Most importantly, do not forget to read about the ABCDE approach in every critically ill and trauma patient.

Brush up on your history taking and examination skills

Know what to ask and when to ask. Patients in the ED are not in their most comfortable composure, so try to practice and frame questions that provide you with just enough information to make a diagnosis in the least possible time.
The same goes for examination, never forget the basics of examination and their importance. Practice examination as much as you can and you will automatically see it come to you naturally at a faster pace. Also, do not forget focused history and physical examination is a cornerstone of EM practice and saves a lot of time.
Where investigations can help you exclude a differential, 80% of your diagnosis will be built from what you ask, what you see and what you feel. Keep in mind that if you are not thinking or looking for something, you will not see and find it. So, be suspicious of life, organ and limb-threatening problems.

Read about common ED procedures

ABG, Intubation, Central Lines, FAST Scan, Suturing, Catheter and Cannula placement are some of them. As a medical student, you will probably not be required to perform any, but it is good to have an idea about the procedures when you see them. If you can practice, then that is even better, ask a resident or intern to show you how and you can have a go yourself under their supervision! Remember, “see one, do one, teach one.”

Watch videos on examination, interpreting X-rays, & procedural skills

Youtube is an asset when it comes to medical education, make good use of it. There are also plenty of videos on the iEM website that you can watch and learn from.

Interpretation of ECG & X-rays

Google is your best friend for this! You have the list of common conditions, all you need to do is a google search on the most common ECG findings and x-rays in medical emergencies and you will be good to go. You can also always learn these from the doctors around you in the ED, as the more you see and try to interpret, the better you get at differentiating the normal from abnormal.

Books

Before the rotation

Before the rotation, read a review book, recall your basic knowledge from internal medicine/family medicine and surgery because EM almost covers all of the acute problems of those fields. Moreover, do not forget, EM is an independent specialty and has its’ own textbooks.

iEM Clerkship book is a very good source to get started with! Download Now! – iEM Book (iBook and pdf)

If you are the kind, who likes solving questions, the Pretest Emergency Medicine is a great source.

During the rotation

During the rotation – Learning what you see is the best way to keep things in your long term memory. After your shift ends, and you go home, get some rest, recall the cases of the day and read about them on Up to Date/ Medscape or any resource that you prefer, this will help you relate what you saw with what you are reading and will help you recall it better later on.

These are just a few tips to help in making the most of your EM rotation. Remember to study hard, but also practice, brush up on your communication skills, talk to patients, be there for them. The EM Clerkship prepares you for life as a doctor, as you practice every aspect of medicine during this time and learn to answer questions about acute medical problems and their severity when asked by those around you.

Cite this article as: Sumaiya Hafiz, "How to make the most of your EM Clerkship," in International Emergency Medicine Education Project, October 4, 2019, https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/, date accessed: November 20, 2019

ELECTRIC SHOCK; Injuries beyond what the eyes see.​

electric shock

Authors: Dr. Nour Saleh and Dr. Kilalo Mjema

Case presentation

A 53-years-old male, sustained burn wounds on both hands 40 minutes prior presentation to the ED

Primary survey

  • Airway: patent and protected.
  • Breathing: bilateral equal air entry
  • Circulation: warm extremities, capillary refill time is 1 second
    • Vitals on presentation
      • BP: 177/114mmHg
      • HR: 115
      • RR: 16
      • SPO2: 96% in room air
      • T: 36.4
  • Disability: alert and oriented, pupils 5mm bilateral equal light reaction, glucose: 7.3mmol
  • Exposure: holding his hands up in pain with some black discoloration

SAMPLE History

  • Sign and symptoms: pain, see pictures
  • Allergy: no known allergies
  • Medications: not on any medication
  • Past medical history: no known comorbid or any significant medical history
    Last meal: he ate about 2.5 hours prior presentation
  • Event: pain on both hands after sustaining burn injury forty minutes prior presentation to the ED while trying to connect two circuits that sparked causing burn wounds on his hands and felt a jolt of electricity.

No history of heartbeat awareness or any loss of consciousness

electrical injury
electrical injury

Interventions and key steps in management

  • Make sure ABCD is checked and there is no critical intervention needed
  • IV access and fluid resuscitation may be considered depending on the case
  • Analgesics: depends on the severity of pain. Fentanyl 50mcg IV stat can be necessary for many patients.
  • Informed consent for procedural sedation for the dressing of the wounds.
  • Sedation: during the dressing of wounds
  • Point-of-care investigations: ECG, Urine dipstick
  • Blood samples for some labs should be taken; Creatinine, CK, Myoglobin, Electrolytes, Calcium, and Troponin
  • Imaging: X-ray if there is a worry for associated fracture
  • Monitor: input of fluids and output of urine to watch for acute kidney injury, compartment syndrome and rhabdomyolysis
  • Do not forget tetanus immunization

Associated injuries

  • Cardiac arrhythmias

    Ventricular fibrillation is the most common. It occurs in 60% of patients with electrical current traveling from one hand to the other.

  • Renal - Rhabdomyolysis

    Massive tissue necrosis may result in acute kidney injury. Labs to check includes; Creatinine, Blood Urea Nitrogen, Total CK, myoglobin.

  • Neurological

    Damage to both central and peripheral nervous systems can occur. The presentation may include weakness or paralysis, respiratory depression, autonomic dysfunction, memory disturbances, loss of consciousness.

  • Skin

    Degree of injury cannot determine the extent of internal damage especially with low voltage injuries. Minor surface burns may co-exist with massive muscle coagulation and necrosis.

  • Musculoskeletal

    Bones have the highest resistance of any body tissues resulting in the greatest amount of heat when exposed to an electrical current. Results in surrounding tissue damage and potentially may lead to periosteal burns, destruction of bone matrix and osteonecrosis.

  • Vascular / Coagulation system

    Due to electrical coagulation of small blood vessels or acute compartment syndrome.

  • Internal organs

    The internal organ injury is not common but when it happens may result serious problems such as bowel perforations leading to polymicrobial infection, sepsis, and death.

Disposition

Admission and discharge decisions of burn patients depend on the patient’s current situation, burn percentage according to body surface area, location of the burn, and complications of burn. Low voltage electrocutions, if they are asymptomatic with normal physical examinations, can be discharged. Discharge precautions regarding burn care and complications should be clearly explained to the patient and relatives.

Further Reading

Cite this article as: Kilalo Mjema, "ELECTRIC SHOCK; Injuries beyond what the eyes see.​," in International Emergency Medicine Education Project, October 2, 2019, https://iem-student.org/2019/10/02/electric-shock-injuries-beyond-what-the-eyes-see-%e2%80%8b/, date accessed: November 20, 2019

Learning Experiences in the ED

Introduction

Every student, regardless of the area and grade, should have recognized that the process of learning is different depending on the environment and the situation. For medical students, it very often depends on the clinical rotation, the type of structure of the hospital and the epidemiologic profile of the population in the area. Thinking about the Emergency Department (ED), we have critical patients, urgent measures to be taken and no much time to have second thoughts, all of this in a very dynamic – sometimes chaotic – environment.

What is the evidence on Medical Education in the ED? How can we improve our experience as a student in such context? Is it possible to have – and give – good feedback? These are some of the points we are discussing in this article, which features a quick conversation with one of the most incredible and enthusiastic emergency physicians I ever know – and who has taught me a lot.

Juliana is an Emergency Physician. I had the pleasure to learn from her with in the field, as well as attending some of her brilliant lectures for the EMIG which I’m part of. She work as an emergency physician in São Paulo and th coordinator of the “Basic and Advanced Airway Digital Course."

What are the singularities you see when giving and receiving feedback in Emergency Department?

“It’s a very dynamic environment and, sometimes, the moment for feedback can be completely ignored if the opportunity is not taken at the right time since the room can always become even more chaotic. For me, one of the greatest advantages is that everything is happening here and now, and the learner can be observed and taught closely. However, this could be a problem if the learner feels insecure while being watched, or if the professor interferes too much during the procedure or the history taking and examination.”

How do you think learning takes place in this environment? Is it possible to learn and teach with each case without disturbing the emergency dynamics?

As I said earlier, although it is a very dynamic environment, I see an emergency department as a valuable environment for the teaching-learning process because we can take advantage from each case in its entirety (from the evaluation to the outcome) or in key situations, important for that learner. Also, the fact that the patient is right there, requiring interventions, instigates the student to want to participate, take action and understand what is going on. Another thing I like very much about teaching in this environment is how we can be very practical in exemplifying and exercising the ED mindset, developing in the learner the clinical reasoning of the emergency, which, as we know, operates in a different logic.”

With the recognition of the specialty in Brazil, what can change in relation to the teaching and mentoring in the emergency department?

“I think the change that many of us are already experiencing is to have emergency medicine specialists in these settings, which qualifies the teaching of mindset and the purpose of acute and severe patient care.”

What tips would you give to students who go through emergency medicine internships to learn more and better?

“One exercise I often do with my students is to always think not about what the patient has, but what he needs. In many cases, the definitive diagnosis is absolutely secondary in immediate care. That is the mindset. Another important point is to observe the emergency room like an orchestra, which the emergency physician is there to conduct: how do we organize physical space? What should I solve first? What patient needs most of my attention right now? What people from the multidisciplinary team are fundamental there? these are skills that we develop with practice, sometimes even without noticing, but when we pay attention to all of this we understand the complexity of the critical care, of the specialty, and the potential that the emergency medicine has in changing patient’s outcomes.”

And for teachers and residents, what tips would you give to improve students learning from the ED routine?

“Everything that shows up is an opportunity for learning, including an empty room, without patients: if you knew how much students don’t know about the physical organization of the room, support materials and ventilators, monitors, defibrillators, multi-professional teams and so on, we would not feel moments without patients as idle time. So I wanted to tell you never to let go of these moments. Another thing that is poorly discussed by us, but that in the Emergency Medicine is essential: health policies, emergency departments situation, organization of health structures. Emergency medicine is an excellent thermometer to measure the efficiency of the system and, if we stop and think a little, to discuss and debate the context that we are inserted (even without all the answers), we develop a more critical and interested generation, not only in Emergency Medicine but in improving the system as a whole.”

Cite this article as: Arthur Martins, "Learning Experiences in the ED," in International Emergency Medicine Education Project, July 1, 2019, https://iem-student.org/2019/07/01/learning-experiences-in-the-ed/, 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

Undergraduate Emergency Medicine Clerkship: Ethiopian Experience

Emergency Medicine (EM) is about timely intervention and management of acute and life-threatening conditions (1). Every medical school graduate should learn and practice basic, yet important interventions for critically ill patients.

There are increased efforts in incorporating EM training into undergraduate curriculum worldwide (2, 3). However, the specialty of EM itself is yet not fully developed in low resource settings (4). South Africa is the first country starting to develop an EM system in Africa (5).

The modern medical education for both undergraduates and postgraduates level started in Ethiopia, at Addis Ababa University, in 1964. However, EM training as a specialty begun in the year 2010 (See infographic below). It was initially fragmented into different departments.

EM was also a 7-week separate elective rotation for undergraduates in the revised curriculum of 2008. It was successfully launched as training in 2013 with 300 4th year medical students (75 students in 4 groups). Students rotate in Adult EM (3 weeks), Pediatric EM (2 weeks) and Anesthesiology (2 weeks). Department of Emergency Medicine is the primary department controlling and managing these rotation areas in the clerkship. Our teaching program is primarily covered by EM, Pediatric EM, and Anesthesiology faculty. It includes practical demonstrations and simulation learning through our EM residents.

Topics covered by EM clerkship include:

Adult EM rotation

  • Introduction to EM
  • Basic Life Support (BLS)
  • Advanced Cardiac Support(ACLS)
  • Advanced Trauma Life Support(ATLS)
  • Approach to chest pain
  • Basic ECG and common arrhythmias
  • Approach to respiratory emergencies
  • Electrolyte emergencies
  • Approach to acute confusional state and neurological emergencies
  • Endocrine emergencies
  • Hypertensive emergencies
  • Approach to the poisoned patient and common toxicological emergencies

Anesthesiology rotation

  • Basic airway management devices 
  • Oxygen therapy
  • General and regional anesthesia with class discussions and practical demonstrations

Pediatric EM rotation

  • Pediatric assessment triangle
  • Pediatric advanced life support (PALS)
  • Newborn resuscitation
  • Common pediatric emergencies

Teaching methods are classroom didactics, case discussions, low fidelity simulations for basic airway management and ATLS demonstrations as well as case-based role plays for scenarios like Acute Myocardial Infarction, and so on.

Thus, in delivering such an innovative form of undergraduate rotation, our department has been selected as the best teaching department for the past 4 years consecutively by graduating medical students.

Cite this article as: Temesgen Beyene, "Undergraduate Emergency Medicine Clerkship: Ethiopian Experience," in International Emergency Medicine Education Project, May 22, 2019, https://iem-student.org/2019/05/22/undergraduate-emergency-medicine-clerkship-ethiopian-experience/, date accessed: November 20, 2019