Emergency Medicine Simulation Research Articles

Applying simulation learning theory to identify instructional strategies for Generation Z emergency medicine residency education

AbstractIntroductionGeneration Z learners are entering emergency medicine (EM) residency training, bringing unique learning preferences that influence their engagement with residency education. To optimally teach and motivate this incoming generation of learners, EM educators must understand and adapt to the changing instructional landscape.MethodologyThe Simulation Leaders Advancing the Next Generation in Emergency Medicine (SLANG‐EM) Workgroup was created to identify effective educational strategies for Generation Z learners entering EM. Members were faculty in the Society for Academic Emergency Medicine (SAEM) Simulation Academy, well versed in learning theory supporting simulation‐based education (SBE) and actively involved in EM residency education.Unique treatment/analysisThrough primary and secondary literature searches, the SLANG‐EM Workgroup identified four distinctive learning preferences of Generation Z learners: (1) individualized and self‐paced learning, (2) engaging and visual learning environments, (3) immediate and actionable feedback, and (4) combined personal and academic support. Workgroup members evaluated these learning preferences using a novel conceptual framework informed by the theoretical principles underpinning SBE, recommending instructional strategies for Generation Z EM residency learners across multiple educational environments.Implications for educatorsInstructional strategies were described for the didactic, simulation, and clinical learning environments. In the didactic environment, identified instructional strategies included meaningful asynchronous education, interactive small‐group learning, and improved multimedia design. In the simulation environment, educational innovations particularly suitable for Generation Z learners included learner‐centered debriefing, rapid‐cycle deliberate practice, and virtual simulation. In the clinical environment, described instructional strategies involved setting learner‐centered goals and delivering facilitative feedback in the context of an educational alliance. Overall, these instructional strategies were clustered around themes of student‐centered education and the educator as facilitator, which align well with Generation Z learning preferences. These findings were synthesized and presented as an advanced workshop, “Delivering Effective Education to the Next Generation,” at the 2023 SAEM Annual Meeting.

LGBTQ+ individuals are not explicitly represented in emergency medicine simulation curricula

Background Medical educational societies have emphasized the inclusion of marginalized populations, including the lesbian, gay, bisexual, transgender and queer (LGBTQ+) population, in educational curricula. Lack of inclusion can contribute to health inequality and mistreatment due to unconscious bias. Little didactic time is spent on the care of LGBTQ+ individuals in emergency medicine (EM) curricula. Simulation based medical education can be a helpful pedagogy in teaching cross-cultural care and communication skills. In this study, we sought to determine the representation of the LGBTQ+ population in EM simulation curricula. We also sought to determine if representations of the LGBTQ+ population depicted stigmatized behavior. Methods We reviewed 971 scenarios from six simulation case banks for LGBTQ+ representation. Frequency distributions were determined for major demographic variables. Chi-Squared or Fisher’s Exact Test, depending on the cell counts, were used to determine if relationships existed between LGBTQ+ representation and bank type, author type, and stigmatized behavior. Results Of the 971 scenarios reviewed, eight (0.82%) scenarios explicitly represented LGBTQ+ patients, 319 (32.85%) represented heterosexual patients, and the remaining 644 (66.32%) did not specify these patient characteristics. All cases representing LGBTQ+ patients were found in institutional case banks. Three of the eight cases depicted stigmatized behavior. Conclusions LGBTQ+ individuals are not typically explicitly represented in EM simulation curricula. LGBTQ+ individuals should be more explicitly represented to reduce stigma, allow EM trainees to practice using gender affirming language, address health conditions affecting the LGBTQ+ population, and address possible bias when treating LGBTQ+ patients.

Pediatric Emergency Medicine Didactics and Simulation (PEMDAS): Pediatric Sedation Complications.

Ketamine and propofol are commonly used agents for sedation in the pediatric emergency department (PED). While these medications routinely provide safe sedations, there are side effects providers should be able to recognize and manage. Currently, no pediatric sedation simulations exist in the literature. We created two sedation simulation cases for learners, including pediatric emergency medicine (PEM) fellows, working in the PED: case 1, a 12-year-old male with a shoulder dislocation requiring reduction under propofol sedation, and case 2, a forearm fracture requiring reduction under ketamine sedation. Learner actions included setting up equipment for sedations, dosing medications correctly, and managing complications. Additionally, in case 2, learners assigned an American Society of Anesthesiologists classification and selected the appropriate candidate for PED sedation from amongst three patients. A debrief followed the cases. Next, a didactic presentation reinforced concepts discussed in the debrief. Participants then completed an evaluation of the simulation. Fifty-eight emergency medicine residents and PEM fellows across four sites at three institutions participated. Participants scored the simulations and the debriefing session on a 5-point Likert scale. Learners rated the scenario as clinically relevant (M = 4.37) and effective at improving their comfort level in caring for critically ill patients (M = 4.36). Learners felt the debrief provided valuable learning (M = 4.40) and was a safe learning environment (M = 4.50). These cases can be utilized as resources for learners in any emergency department and can be tailored to any training background of learner providing sedation.

Fostering Proficiency in Essential Skills among Emergency Medicine Residents through Simulation-Based Education

Introduction: Simulation-based education has become a crucial element within emergency medicine (EM) residency programs. Medical education places great emphasis on competency-based assessments, and high-fidelity simulation has emerged as an effective methodology to support these assessments. Objective: The Accreditation Council for Graduate Medical Education (ACGME) defines a set of core competencies that healthcare professionals must acquire to ensure the delivery of safe and effective patient care. In our study, we sought to investigate the impact of simulation-based education on the enhancement of ACGME core competencies among emergency medicine residents. Method: We conducted a prospective observational study at our institute, involving all current EM residents. Each month, we conducted a high-fidelity immersive simulation session, featuring three separate scenarios for both first year (R1) and second year (R2) residents. From August 2020 to April 2023, a total of 36 simulation sessions were conducted, encompassing 108 scenarios. To assess performance in clinical and non-technical skills, the expert faculty used our custom-designed objective structured assessment tool, the Emergency Medicine Simulation Assessment Tool (EMSAT). This tool evaluated performance across 15 sub-tasks (9 (60%) clinical and 6 (40%) non-technical skills). Each sub-task was mapped to the ACGME core competency; Patient Care (PC), Medical Knowledge (MK), Practice Based Learning (PBL), Systems Based Practice (SBP), Interpersonal and Communication Skills (ICS), and Professionalism (P). The achieved scores for each competency were converted into percentages for analysis. The data was divided into two groups. The first 18 sessions (54 scenarios) formed phase-I, while the last 18 sessions (54 scenarios) constituted phase-II. A two-tailed paired T-test was utilized to compare the two phases. Our primary outcome measure focused on the improvement observed across all six ACGME core competencies. Results: The paired T-test results revealed a significant and substantial difference in all six core competencies between phase-I and phase-II. The mean scores demonstrated a significant improvement between two phases i.e., PC (M=55.1, M=84.4), MK (M=57.2, M=83.6), PBL (M=60.5, M=88.4), SBP (M=62.2, M=89.7), ICS (M=61.8, M=89.7), and P (M=64, M=89.9). Conclusion: The implementation of high-fidelity immersive simulations in the training of emergency medicine residents yielded remarkable advancements across all six ACGME core competencies.

A22The use of simulation in paediatric emergency medicine: a scoping review

The use of simulation in healthcare has increased in recent years. It is frequently used for replicating clinical scenarios and allows for the acquisition of skills in a safe environment. Whilst enabling candidates to make mistakes and learn from them without fear of harming patients is used across many specialities including paediatric emergency medicine for a range of teaching across all professional groups, Lateef [1] identifies that in order for it to reach its maximum potential, it needs to be integrated in traditional training programmes. This is becoming more commonplace. In order to know how to fully integrate it into practice, an understanding of how it is currently being used is essential. This scoping view aims to explore how simulation training is being used and what it is used for within paediatric emergency medicine (PEM), as reported by the literature. This review followed a five-step scoping review framework outlined by Arksey and O’Malley [2]. Literature searches were conducted in Medline and CINAHL with no limitation applied. Sixty-six studies were screened. Reference lists were also screened. Of the screened studies, 25 were subject to full test review and 19 were included in the final review. Articles were screened at all levels by one reviewer. Data extraction was also carried out by one reviewer. No papers focused on the delivery of simulation within paediatric emergency medicine in the UK, with the majority of papers originating from the USA. There was also no paper that outlined the varied uses of simulation in PEM. Many of the papers described and evaluated single scenarios that were used in varying settings or simulation courses that were not specific to PEM. Both high and low fidelity simulations were reported with much of the focus on high-fidelity simulation. Delivered through either simulation suite-based learning or This scoping review reveals that the extent to which simulation is used within PEM is largely unknown and requires further investigation. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Using In Situ Simulation to Identify Latent Safety Threats in Emergency Medicine: A Systematic Review.

This review aimed to explore existing literature on the use of in situ simulation to identify latent safety threats in emergency medicine. Studies were required to take place in a clinically active emergency department and have either a primary or secondary aim of identifying latent safety threats. A total of 2921 articles were retrieved through database searches and a total of 15 were deemed to meet the inclusion criteria.Latent safety threats were detected by a variety of methods including documentation during debrief/discussion (66%), during the simulation itself (33%), participant surveys (20%), and video analysis (20%). Using a multimodality approach with input from observers and participants from different professional backgrounds yielded the highest number of threats per simulation case (43 per case). Equipment was the most commonly reported threat (83%), followed by teamwork/communication (67%). Some studies did not report on mitigation of identified risks; formal processes should be implemented for the management of latent safety threats identified by in situ simulation. Future research should focus on translational outcomes to further strengthen the position of in situ simulation in emergency medicine.

Pediatric Emergency Medicine Didactics and Simulation: JumpSTART Secondary Triage for Mass Casualty Incidents.

Mass casualty incidents (MCI), particularly involving pediatric patients, are high-risk, low-frequency occurrences that require exceptional emergency arrangements and advanced preparation. In the aftermath of an MCI, it is essential for medical personnel to accurately and promptly triage patients according to their acuity and urgency for care. As first responders bring patients from the field to the hospital, medical personnel are responsible for prompt secondary triage of these patients to appropriately delegate hospital resources. The JumpSTART triage algorithm (a variation of the Simple Triage and Rapid Treatment, or START, triage system) was originally designed for prehospital triage by prehospital providers but can also be used for secondary triage in the emergency department setting. This technical report describes a novel simulation-based curriculum for pediatric emergency medicine residents, fellows, and attendings involving the secondary triage of patients in the aftermath of an MCI in the emergency department. This curriculum highlights the importance of the JumpSTART triage algorithm and how to effectively implement it in the MCI setting.

Simulation for diversity, equity and inclusion in emergency medicine residency training: A qualitative study.

The last few years have seen an increased focus on diversity, equity, and inclusion (DEI) initiatives across organizations. Simulation has been used in varying degrees for teaching about DEI topics with emergency medicine; however, there are no established best practices or guidelines on this subject. To further examine the use of simulation for DEI teachings, the DEISIM work group was created as a collaboration between the Society of Academic Emergency Medicine (SAEM) Simulation Academy and the Academy for Diversity and Inclusion in Emergency Medicine (ADIEM). This study represents their findings. This qualitative study was conducted using a three-pronged approach. Initial literature search was conducted followed by a call for submission of simulation curricula. These were then followed by five focus groups. Focus groups were recorded, transcribed by a professional transcription service, and then subjected to thematic analysis. Data were analyzed and organized into four broad categories including Learners, Facilitators, Organizational/Leadership, and Technical Issues. Challenges within each of these were identified, as were potential solutions. Select pertinent findings included focused faculty development, a carefully planned approach that utilized DEI content experts and the use of simulation for workplace microaggressions or discriminations. There appears to be a clear role for simulation in DEI teachings. Such curricula, however, should be undertaken with careful planning and input from appropriate and representative parties. More research is needed on optimizing and standardizing simulation-based DEI curricula.

Implementation of a North American pediatric emergency medicine simulation curriculum using the virtual resuscitation room.

Simulation provides consistent opportunities for residents to practice high-stakes, low-frequency events such as pediatric resuscitations. To increase standardization across North American residency programs, the Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) was developed. However, access to high-quality simulation/pediatric expertise is not uniform. As the concurrent COVID-19 pandemic necessitated new virtual simulation methods, we adapted the Virtual Resus Room (VRR) to teach EM ReSCu Peds. VRR is an award-winning, low-resource, open-access distance telesimulation platform we hypothesize will be effective and scalable for teaching this curriculum. EM residents completed six VRR EM ReSCu Peds simulation cases and received immediate facilitator-led teledebriefing. Learners completed retrospective pre-post surveys after each case. Learners and facilitators completed end-of-day surveys. Primary outcomes were learning effectiveness measured by a composite of the Simulation Effectiveness in Teaching Modified (SET-M) tool and self-reported changes in learner comfort with case objectives. Secondary outcome was VRR scalability to teach EM ReSCu Peds using a composite outcome of net promoter scores (NPS), resource utilization, open-text feedback, and technical issues. Learners reported significantly increased comfort with 95% (54/57) of EM ReSCu Peds-defined case objectives (91% cognitive, 9% psychomotor), with moderate (Cohen's d 0.71, 95% CI 0.67-0.76) overall effect size. SET-M responses indicated simulation effectiveness, particularly with debriefing. Ninety EM residents from three North American residency programs were taught by 59 pediatric faculty from six programs over 4 days-more than possible if simulations were conducted in person. Learners (39) and faculty (68) NPS were above software industry benchmarks (13). Minor, quickly resolved, technical issues were reported by 18% and 29% of learners and facilitators, respectively. Learners and facilitators report that the VRR is an effective and scalable platform to teach EM ReSCu Peds. This low-cost, accessible distance simulation intervention could increase equitable, global access to high-quality pediatric emergency education.

Identifying Royal College-accredited simulation centre research priorities across Canada.

To advance the field of health sciences simulation, research must be of high quality and would benefit from multi-institutional collaboration where centres can leverage and share expertise as well as work together to overcome limits to the generalizability of research findings from single-institution studies. A needs assessment in emergency medicine simulation has illustrated the importance of identifying research priorities in Canada. The main purpose of this study was to identify simulation research priority directions for Canadian simulation centres. The current survey study drew on 16 research priorities developed through a two-round internal Delphi study at McGill University that 15 of 17 simulation centre advisory board members participated in. The final 16 research priorities were then rated by a total of 18 of 24 simulation centre directors and/or delegates contacted from 15 of 19 Royal College of Physicians and Surgeons of Canada-accredited simulation centres in Canada. Results revealed nine common research priorities that reached 70% or higher agreement for all respondents. We anticipate that our findings can contribute to building a shared vision of priorities, community, and collaboration to enhance health care simulation research quality amongst Canadian simulation centres.

Technology-enhanced simulation in emergency medicine: Updated systematic review and meta-analysis 1991-2021.

Over the past decade, the use of technology-enhanced simulation in emergency medicine (EM) education has grown, yet we still lack a clear understanding of its effectiveness. This systematic review aims to identify and synthesize studies evaluating the comparative effectiveness of technology-enhanced simulation in EM. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, Web of Science, and Scopus to identify EM simulation research that compares technology-enhanced simulation with other instructional modalities. Two reviewers screened articles for inclusion and abstracted information on learners, clinical topics, instructional design features, outcomes, cost, and study quality. Standardized mean difference (SMD) effect sizes were pooled using random effects. We identified 60 studies, enrolling at least 5279 learners. Of these, 23 compared technology-enhanced simulation with another instructional modality (e.g., living humans, lecture, small group), and 37 compared two forms of technology-enhanced simulation. Compared to lecture or small groups, we found simulation to have nonsignificant differences for time skills (SMD 0.33, 95% confidence interval [CI] -0.23 to 0.89, n= 3), but a large, significant effect for non-time skills (SMD 0.82, 95% CI 0.18 to 1.46, n= 8). Comparison of alternative types of technology-enhanced simulation found favorable associations with skills acquisition, of moderate magnitude, for computer-assisted guidance (compared to no computer-assisted guidance), for time skills (SMD 0.50, 95% CI -1.66 to 2.65, n= 2) and non-time skills (SMD 0.57, 95% CI 0.33 to 0.80, n= 6), and for more task repetitions (time skills SMD 1.01, 95% CI 0.16 to 1.86, n= 2) and active participation (compared to observation) for time skills (SMD 0.85, 95% CI 0.25 to 1.45, n= 2) and non-time skills (SMD 0.33 95% CI 0.08 to 0.58, n= 3). Technology-enhanced simulation is effective for EM learners for skills acquisition. Features such as computer-assisted guidance, repetition, and active learning are associated with greater effectiveness.

Simulation device for shoulder reductions: overview of prototyping, testing, and design instructions

BackgroundShoulder dislocations are common occurrences, yet there are few simulation devices to train medical personnel on how to reduce these dislocations. Reductions require a familiarity with the shoulder and a nuanced motion against strong muscle tension. The goal of this work is to describe the design of an easily replicated, low-cost simulator for training shoulder reductions.Materials and methodsAn iterative, stepwise engineering design process was used to design and implement ReducTrain. A needs analysis with clinical experts led to the selection of the traction-countertraction and external rotation methods as educationally relevant techniques to include. A set of design requirements and acceptance criteria was established that considered durability, assembly time, and cost. An iterative prototyping development process was used to meet the acceptance criteria. Testing protocols for each design requirement are also presented. Step-by-step instructions are provided to allow the replication of ReducTrain from easily sourced materials, including plywood, resistance bands, dowels, and various fasteners, as well as a 3D-printed shoulder model, whose printable file is included at a link in the Additional file 1: Appendix.ResultsA description of the final model is given. The total cost for all materials for one ReducTrain model is under US $200, and it takes about 3 h and 20 min to assemble. Based on repetitive testing, the device should not see any noticeable changes in durability after 1000 uses but may exhibit some changes in resistance band strength after 2000 uses.DiscussionThe ReducTrain device fills a gap in emergency medicine and orthopedic simulation. Its wide variety of uses points to its utility in several instructional formats. With the rise of makerspaces and public workshops, the construction of the device can be easily completed. While the device has some limitations, its robust design allows for simple upkeep and a customizable training experience.ConclusionA simplified anatomical design allows for the ReducTrain model to serve as a viable training device for shoulder reductions.

The ABCDE (Avoid Shaming/Personal Opinions, Build a Rapport, Choose a Communication Approach, Develop a Debriefing Content, Ensure the Ergonomics of Debriefing) Approach: A Simplified Model for Debriefing During Simulation in Emergency Medicine.

Several debriefing models have been described in the literature. However, all these debriefing models are designed in the general medical education format. Hence,for people involved in patient care and clinical teaching, sometimes it may become tedious and difficult to incorporate these models. In the following article, we describe a simplified model for debriefing using the well-known mnemonic ABCDE. The ABCDE approach is expanded as follows: A - Avoid Shaming/Personal Opinions, B - Build a Rapport, C - Choose a Communication Approach, D - Develop a Debriefing Content, and E - Ensure the Ergonomics of Debriefing. The unique thing about this model is that it provides a debriefing approach as a whole rather than only the delivery. It deals with human factors, educational factors, and ergonomics of debriefing, unlike other debriefing models.This approach can be used for debriefing by simulation educators in the field of emergency medicine and also by educators in other specialties.

Safe and Sound: An Improvisational Theater-Based Curriculum and Behavioral Intervention to Address Violence in the Emergency Department

Background: Emergency department (ED) workplace violence has become increasingly prevalent in the United States, warranting the development of legislation, policy, and advocacy to protect health care workers. Solutions to address ED violence remain limited, and staff-oriented trainings often exist as short, one-time didactic sessions, which are not practical nor often applicable to the ED setting. There is a paucity of evidence-based interventions that incorporate behavioral-based training to adequately prepare staff for the complicated, multifactorial presentation of violence in the ED. Objective: This pilot study sought to assess the feasibility of an improvisational theater–based, simulation intervention for health care professionals to address ED violence. Methods: A longitudinal curriculum for ED violence was developed in collaboration with a committee of emergency medicine (EM) faculty, EM simulation experts, hospital security and police personnel, professional theater and improvisational performers, resident physicians, and medical students. This pilot intervention was tailored to new EM residents (n = 25) at a large, urban, academic medical center. Sessions were led by facilitators trained in group facilitation, simulation, and improvisation. Results: Participants felt the curriculum was helpful (82.6%), engaging (91.3%), applicable (73.9%), and enjoyable (82.6%). Participation primarily by residents identifying as female and people of color suggested the efficacy of creative expression and nontraditional modalities in engaging diverse learners. Ninety-five percent of participants expressed interest in future sessions. Conclusions: A multidisciplinary workplace violence intervention leveraging principles of improvisational theater, health equity, organizational psychology, and EM simulation may prove useful in preparing health care professionals for violence in the ED.

Exploring the Frameworks, Needs, and Barriers of Interprofessional Education and Simulation in Emergency Medicine.

This manuscript focuses on interprofessional education (IPE) using simulation and its use between emergency department and emergency medical services personnel. It explores the theoretical frameworks behind IPE and applies them to simulation-based emergency medical services education. There is a notable lack of research on the use of IPE using simulation between these 2 professions. The need for IPE using simulation as well as barriers and recommendations to remove the barriers are discussed.

Testing the robustness of emergency department process pathways using multidisciplinary team in-situ simulation

Delivering safe and best practice is dependent on robust structural processes and optimal acquisition of skills and knowledge across disciplines [1]. An in-situ simulation-based education model was implemented to optimise the provision of best practice in emergency medicine [2]. In-situ simulation cases were developed based on critical incidents, complaints, and interesting cases. These simulations were designed to be complex cases, aimed at high-level multi-specialty working. Maintaining the real-life integrity of the simulation cases was paramount. The simulations were run in a busy Emergency Department (ED), during the working day while the normal service continued. Participants were instructed to make-up medication, collect blood products, and contact specialities in real time. Debriefing initially included identifying communication, human factor and process issues, and concluded with medical teaching on the topic covered, and included the speciality perspective on optimal medical management. Logistical support was provided by the simulation faculty. Data from feedback forms was collected. Over 12 months, 20 simulations cases were conducted in the resuscitation area of the ED. Simulations involved multidisciplinary, multi-speciality workforce covering the management of acute bronchitis in an infant, an episode of acute psychosis, upper gastrointestinal bleed requiring major haemorrhage protocol activation, and many other emergencies covering the full spectrum of specialities. All feedback strongly agreed/agreed that the simulation exercises were beneficial and would lead to an improvement in the participants’ clinical practice. The multidisciplinary approach was key to the discovery of system weaknesses and risk-factors. These were then addressed and improvements in system learning, and processes were proven by the re-running of similar scenarios. The learning points were communicated via the hospital ED guideline application (AskEarl) and departmental communication channels. Changes have included updating standard operating procedures, guidelines, and the application of a business case for a blood fridge located in ED to reduce blood administration length of time. These detailed simulations successfully tested the current hospital processes and resulted in significant improvements to the daily structural delivery of best practise. Additionally, the SBE model decreased clinician teaching preparation burden and increased simulation efficiency and effectiveness. After the success of this model, it is being rolled out to other specialities. We would like to acknowledge and thank the Dinwoodie Charitable Company for their support. 1. Gressgård LJ. Knowledge management and safety compliance in a high-risk distributed organizational system. Safety and health at work. 2014;5(2):53–59. 2. Petrosoniak A, Auerbach M, Wong AH, Hicks CM. In situ simulation in emergency medicine: moving beyond the simulation lab. Emergency Medicine Australasia. 2017;29(1):83–88.

Step up to ST3 emergency medicine simulation course

The UK Emergency Medicine training pathway has three phases; Core (CT1-2), Intermediate (ST3), and Higher (ST4-6) [1]. The transition from Core to ST3 can be daunting – whilst not ‘registrars’, ST3s are often on ‘middle grade’ rotas. Trainees are expected to manage complex adult and paediatric cases with new portfolio requirements to demonstrate these competencies. They further develop leadership skills when supporting junior doctors and managing the department [2]. An ‘Introduction to ST3’ course was developed initially in the North West Deanery to address this transition. Using the original concepts, course content and format were adjusted for a Merseyside step up course. The redesigned three-day course contained workshops including ST3 challenges, paediatrics, night shifts, and wellbeing. 12 scenarios were organised into ‘leadership’ (sick medical and trauma patients), paediatrics (including major trauma and safeguarding), and ‘challenges’ (e.g. behavioural disturbance, burns, managing conflict with colleagues and supporting juniors). They took place in a simulation suite with either manikins or simulated patients. Data were analysed pre-course, post-course, and at one to two years post-course with thematic analysis used for free-text responses. 47 candidates took part in 2019–2021. Pre-course questionnaires showed a key concern was caring for paediatric patients. Other themes were supporting juniors, management skills, being an isolated leader, and confidence. Contemporaneous feedback showed the simulations and talks were rated positively throughout. Simulations were challenging and rated as a useful aspect. The highest rated talks have been night shift work (9.78/10, n=18), supervising others (9.67/10, n=12), and paediatrics (9.67/10, n=12). Improved confidence particularly in challenging situations has been a common theme. Lower rated talks from 2019 were replaced subsequently, and the course remains receptive to feedback. In 2021, ‘The Floor’ game [3] was incorporated for departmental management skills and participants found this particularly useful. One to two years later, candidates reiterated the importance of the course in their transition, particularly regarding paediatric cases. They highlighted the benefit of discussing portfolio requirements and the value of networking with peers. The step up course has been an important aid when transitioning to ST3 with feedback consistently positive at the time of the course and subsequently. Analysis of this feedback has informed improvements for the 2022 iteration happening shortly, and reinforced aspects including ‘The Floor’, to provide a supportive transition for trainees. As one trainee reported, the course ‘made me excited for ST3, [a] reminder why I’m an ED trainee’. 1. The Royal College of Emergency Medicine, 2021. Curriculum 2021. 2. Walthall K, editor. Introduction to ST3; Course Guide. 2019. 3. Focus Games, 2022. The Floor Game.

Methemoglobinemia.

The targeted audience for this simulation are emergency medicine providers, including residents as well as advanced practice providers, to properly educate on recognizing, diagnosing, and managing methemoglobinemia. Methemoglobinemia is a blood disorder characterized by the presence of ferric form of hemoglobin in the blood. This form of hemoglobin can carry oxygen but is unable to release it effectively causing a range of symptoms including headache, dizziness, nausea, and cyanosis. It is rarely congenital and mostly caused by the exposure to oxidizing agents, such as local anesthetics and quinolones.1 Normally, oxygen can bind to hemoglobin while it is in the ferrous state (Fe2+). In cases of methemoglobinemia, the heme iron configuration is converted from ferrous (Fe2+) to ferric (Fe3+), making it unable to bind to oxygen. As a result, normal ferrous hemes experience an increased affinity for oxygen causing a leftward shift in the oxygen dissociation curve. This in turn causes functional anemia due to reduced oxygen carrying capacity.1 Methemoglobinemia can result from exposure to different medications as well as environmental factors and presents like other disease processes including chronic obstructive pulmonary disease exacerbations. Congenital methemoglobinemia due to cytochrome b5 reductase deficiency is very rare, but the actual incidence is not known. Increased frequency of disease has been found in Siberian Yakuts, Athabaskans, Eskimos, and Navajo.2 Although it is also an unusual occurrence, acquired methemoglobinemia is much more frequently encountered than the congenital form.1In a 10-year retrospective study looking at the incidence rate of topical anesthetic-induced methemoglobinemia, it was found that the overall prevalence was 0.035%. A major risk factor was hospitalization at the time of a procedure being performed. An increased risk was also seen with benzocaine-based anesthetics.3. At the end of this simulation case, participants should be able to: 1) recognize shortness of breath, cyanosis and respiratory distress, and the difference between all of them based on the clinical presentation 2) identify the underlying cause of the condition by conducting a thorough history and physical 3) know how to identify and treat methemoglobinemia by ordering necessary labs and interventions and understand the pathophysiology leading to methemoglobinemia 4) recognize patient's response to treatment and continue to reassess. This is a high-fidelity simulation case that allows participants to evaluate and treat methemoglobinemia in a safe environment. The case is followed by a debriefing and small group discussion to review patient care skills, medical knowledge, interpersonal communication, practice-based learning, and improvement. The educational content and efficacy were evaluated by oral feedback and a debriefing session immediately after completion of the simulation. A 5-point Likert scale was sent out to participants pre-simulation and post-simulation. Questions on the survey included whether they felt confident in their ability to recognize methemoglobinemia, understood the physiology and causes of methemoglobinemia, and felt confident in their ability to treat methemoglobinemia. Sixteen learners responded to the survey, consisting of EM residents and medical students. Post simulation, approximately 92% of EM residents answered agree or strongly agree in their ability to recognize and treat methemoglobinemia compared to pre-sim survey of about 62.5%. Post-simulation feedback also resulted in positive reception, and learners found it useful to run through an uncommonly seen case in the hospital. Results showed overall improvement in recognition and treatment of methemoglobinemia among residents and medical students. This simulation improved recognition of methemoglobinemia including signs and symptoms associated with it. Proper management and treatment options were included such as administration of methylene blue. Overall, this simulation was helpful in teaching EM residents how to recognize, manage, and treat methemoglobinemia. In addition, post-simulation debriefing allowed further discussion among residents, which they found valuable. Methemoglobinemia, shortness of breath, cyanosis, respiratory distress, anemia, methemoglobin, oxygen dissociation curve, emergency medicine simulation.

112 Future Uses of Telesimulation: National Survey of Emergency Medicine Residency Simulation Directors

112 Future Uses of Telesimulation: National Survey of Emergency Medicine Residency Simulation Directors

E-learning and virtual patient simulation in emergency medicine: New solutions for old problems

E-learning and virtual patient simulation in emergency medicine: New solutions for old problems