In some cases, normal saline with additional potassium is required to prevent overcorrection of serum potassium levels which would otherwise result in hypokalaemia. Insert at least onewide-bore intravenous cannula(14G or 16G) and take blood tests as discussed below. This is a combination of the modified traditional lecture within scenario-based learning. Simulation-based medical education: An ethical imperative. Open the patients airwayusing ahead-tiltchin-lift manoeuvre: 1. Clearlydocument your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patients response. She Died the Next Day. In this case scenario, dehydration is one of the most serious immediate issues. Calculate the patients current fluid balance using their fluid balance chart (e.g. Some error has occurred while processing your request. Antibiotics should be prescribed in keeping with local guidelines. Collectblood testsafter cannulating the patient including: An ECG should be performed to screen for cardiac pathology such as arrhythmias which may be precipitated by electrolyte abnormalities (e.g. Causes: Any situation arising in a diabetic that requires increased insulin without that demand being met can result in DKA. . endobj This video demonstrates how to use the SOCRATES acronym when taking a history of pain or other symptoms. The instructors role is to facilitate active learning through a combination of learning styles. If the patientloses consciousnessand there areno signs of lifeon assessment, put out acrash callandcommence CPR. unilateral coarse crackles may be present if the patient has pneumonia which may have been the precipitant for DKA). They have had no clinical exposure or any clinical experience. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 595.32 841.92] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> There are actually two sets of educational objectives: the first set is for the theoretical PBL sessions, and the 2nd set is for the Simulation Session. Just place the BR2_KDCA file into your addons scenery folder: C:\\Program Files\\Microsoft Games\\Microsoft Flight Simulator X\\Addon Scenery\\Scenery. In this section, we have to guide them as to what they should do first for the patient in this critical condition (ie, treat the A, B, Cs of airway, breathing, and circulation) before we can confirm the diagnosis. A collection of communication skills guides, for common OSCE scenarios, including history taking and information giving. Review the patients drug chart for medications which may cause a reduced level of consciousness (e.g. However, this leads to confusion. Abdomen: The abdominal examination reveals diffuse mild epigastric tenderness to deep palpitation but neither rebound tenderness nor guarding (result of examination given by patient or by instructor). The use of case-based simulation, although more complicated and time consuming for the instructor, immerses the students in the subject matter. It involves working through the following steps: Each stage of the ABCDE approach involvesclinicalassessment,investigationsandinterventions. The scenario would include an if-then algorithm. Depending on scenario complexity, team dynamic and treatment modalities, this simulation may take 1020 minutes. angioedema, rash) commence appropriate treatment as discussed in ouranaphylaxis guide. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. Evenly balancing performance measures will ensure the student has the opportunity to critically think through patient treatment and to practice new or support previously learned behaviors and technical skills. Please enable scripts and reload this page. Instagram: https://instagram.com/geekymedics 2) Complete the assigned suggested readings 3) Complete the presimulation preparation virtual simulation game (Instructor will provide link) 4) Once you have completed reading this document and prepared for your simulation, please: a. Measure the patients capillary blood glucose and ketone levels to confirm the diagnosis and guide the management of DKA. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction. The files are given in full in the web supplement (Appendix B, Supplemental Digital Content 2, https://links.lww.com/SIH/A2). Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journals Web site (www.simulationinhealthcare.com). A hyperglycemic patient may present with tachypnea, which often presents as Kussmauls respirations, tachycardia, orthostatic blood pressure changes and other signs of dehydration and diabetic ketoacidosis (DKA). We try to provide sufficient realism.. In the final 10 minutes, we show how the patient has a good recovery after fluid replacement. Trainee will practice or observe good teamwork skills, both as a leader and a team player. may email you for journal alerts and information, but is committed If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR. DY{Qb"(EgN$QI*%XN1F""0a5 Margolis GS, Romer GA, Fernandez AR, et al. The instructor should have visual access via one-way windows or cameras. *=NdL/c2XSJn8:I Jb8'.8>N*[L .hxw6afq40DX3c~>abt'Q,8y(BZu(vKBTufIR. Reprints: Koichiro Nandate, MD, PhD, Department of Anesthesiology, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, 500 University Drive Box 850, Hershey, PA 17033 (e-mail: [emailprotected]). The consequences (low blood pressure, high heart rate, central nervous system status, etc.) Indeed, it is the only thing that ever has.". A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. Trigger 4, Pathway 1l of saline required over 1hour and insulin infusion need prescribing and making up in 50ml syringe. can be reemphasized, and the effects of fluid therapy demonstrated. Ask for anotherclinicalmemberofstafftoassistyou if possible. insulin-dependent type 2 diabetes) Symptoms Typical symptoms of DKA include: Palpitations Nausea Vomiting Sweating Thirst Weight loss Leg cramps Clinical signs Typical clinical signs of DKA include: Tachycardia Hypotension Highlight selected keywords in the article text. Introduction: Diabetic ketoacidosis (DKA) is a life-threatening illness which classically presents with polyuria, polydipsia, and polyphagia that can rapidly progress to severe dehydration and altered mental status from cerebral edema. The validity of the HFS-DKA scenario was verified by a certified diabetes nurse educator, a registered nurse, and a clinical nurse educator. DO NOT perform any examination or procedure on patients based purely on the content of these videos. Before trainees arrival into the simulation area, the simulator is already preprogrammed for DKA. The addition of a fluid infusion containing some potassium allows insulin therapy to continue to suppress ketogenesis and normalise plasma pH whilst preventing the development of hypokalaemia. If the patient has clinical signs ofanaphylaxis(e.g. 1-6. Anesthetic Management Using the Oxygen Reserve Index for Tracheal Resection and Tracheal End-to-E A Scoping Review of the Impact of COVID-19 on Kidney Transplant Patients in the United States, Alabama College of Osteopathic Medicine Research, Baylor Scott & White Medical Center Department of Neurosurgery, California Institute of Behavioral Neurosciences & Psychology, Contemporary Reviews in Neurology and Neurosurgery, DMIMS School of Epidemiology and Public Health, Simulation, Biodesign, & Innovation In Medical Education, The Florida Medical Student Research Publications, University of Florida-Jacksonville Neurosurgery, VCOM Clinical, Biomedical, and Educational Research, American Red Cross Scientific Advisory Council, Canadian Association of Radiation Oncology, International Liaison Committee on Resuscitation, International Pediatric Simulation Society, Medical Society of Delaware Academic Channel, Society for Healthcare & Research Development, Surgically Targeted Radiation Therapy for Brain Tumors: Clinical Case Review, Clinical and Economic Benefits of Autologous Epidermal Grafting, Defining Health in the Era of Value-Based Care, Optimization Strategies for Organ Donation and Utilization, MR-Guided Radiation Therapy: Clinical Applications & Experiences, Multiple Brain Metastases: Exceptional Outcomes from Stereotactic Radiosurgery, Proton Therapy: Advanced Applications for the Most Challenging Cases, Radiation Therapy as a Modality to Create Abscopal Effects: Current and Future Practices, Clinical Applications and Benefits Using Closed-Incision Negative Pressure Therapy for Incision and Surrounding Soft Tissue Management, Negative Pressure Wound Therapy with Instillation, NPWT with Instillation and Dwell: Clinical Results in Cleansing and Removal of Infectious Material with Novel Dressings. The students are in their basic science course. Keywords: diabetic ketoacidosis, simulation, expertise, emergency medicine Introduction Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus, most commonly occurring in patients with type I diabetes. Trainee will get to know how professionals behave during management of a critically ill patient. 6. See ourintravenous cannulation guidefor more details. TheABCDEapproach can be used to perform a systematic assessment of a critically unwell patient. She does not take this regularly. PBL in our institution is implemented as a small group (n 68 students) self study session with a facilitator, who incrementally discloses further information about the patient. Inspect for evidence of self-injection sites (e.g. Given such a small group, the students indicated that they feel more involved than they would with a larger group (eg, the whole class.) Prior to starting the scenario, the instructor should introduce a short summary of the case study and ask open-ended questions regarding the management direction. a simulation training session designed to acquaint emergency medicine residents with the presentation and management of diabetic ketoacidosis (DKA) through the use of simulation. The student group is given a short introduction into a closed simulation environment. Keywords: diabetic ketoacidosis, simulation, expertise, emergency medicine Introduction Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus, most . diagnosis of DKA Trigger 3, ABG show acidosis and high BM and normal potassium. Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ In the first, the authors expanded the National Registrys Longitudinal EMT Attributes and Demographic (LEADS) study by resurveying 1,600 EMS workers about their sleepiness while at work. - Site 01:12 The faculty member/course coordinator of Simulation Design Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment. <>>> Cureus is on a mission to change the long-standing paradigm of medical publishing, where submitting research can be costly, complex and time-consuming. A collection of free medical student quizzes to put your medical and surgical knowledge to the test! Available from: [. Diabetic Ketoacidosis (DKA) Clinical Pathway Emergency Department | Children's Hospital of Philadelphia To read Pages full Research Review column, visit www.jems.com/patient-care. Trainee will describe the changes in vital signs, the major metabolic, fluid, and electrolyte. This guide has been created to assist students in preparing for emergencysimulationsessionsas part of their training,it is not intended to be relied upon for patient care. Marx JA, Hockberger RS, Walls RM. cellulitis). YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LjMxakdNallNcng0, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkJPVjVZMzBKczY4, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkxEM2VkQzB2NTBr, Start typing to see results or hit ESC to close, Deep Vein Thrombosis (DVT) Examination OSCE Guide, Pre-hospital Advanced Life Support (ALS) OSCE Guide, Adult Choking (Basic Life Support) OSCE Guide, Paediatric Intravenous Cannulation OSCE Guide, Intrauterine System (Mirena) Counselling OSCE guide, Geeky Medics OSCE Book | Clinical Examination, Paediatric Gastro-oesophageal Reflux Disease, A Career as a GP with Special Interest with Dr Fiona Mosgrove, Absolute insulin deficiency (e.g. 4 0 obj 3. It may be necessary toexposethe patient during your assessment: remember to prioritise patient dignity and conservation of body heat. Using SOCRATES in History Taking | OSCE | Communication Skills, Diabetic Ketoacidosis (DKA) | Acute Management | ABCDE. Medical Simulation Scenarios are text documents outlining the various details of a simulation - everything from patient simulator settings to debriefing notes.Below is a collection of donated scenarios for you to use or modify. . Refer to your local guidelines which should provide a clear protocol for the management of DKA. The students worked on the underlying physiology during a week long PBL session and are therefore familiar with the theoretical aspects of DKA. DOWNLOAD Diabetic Ketoacidosis By the end of this scenario, the learner will be able to: 1. Diabetic ketoacidosis; Simulation training; Medical students. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. His Heart Stopped On a Treadmill. Make sure tore-assessthe patient after anyintervention. Conclusion Ziv A, Wolpe PR, Small SD, et al. Check out our NEW & IMPROVED quiz platform at geekyquiz.com, To be the first to know about our latest videos, subscribe to our YouTube channel . PA EMT Said COVID Patient Didnt Need to Go to the Hospital. Should any changes be made to the current management of their underlying condition(s)? Make sure to re-assess the patient after any intervention. 1) Please read through this document as it will help you prepare for your upcoming simulation on DKA. Finally, we summarize the course and give them time for questions. This typically involves the use of anon-rebreathe maskwith an oxygen flow rate of15L. Therefore, we should not have to take much time on this issue, but we have to focus on the relationship between the biochemistry and clinical signs and symptoms by asking why the patient is dehydrated, why acidosis develops, why respiration is rapid and deep (Kussmaul) respirations, and what the rationale for inpatient treatment is. One advantage to the animated lecture style is the ability to introduce treatment options in a methodically guided approach thats in conjunction with simultaneous environmental stimulus. However, this turned out to be too slow, took too much time, and could not continuously demonstrate the direction of changes. DKA can be caused by either: Absolute insulin deficiency (e.g. (1) The assessment of a diabetic patient is best taught as a. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. confusion, coma), All critically unwell patients should have. The use of simulation-based instruction enables a student to learn at their own pace and allows them to repeat sequential steps to gain confidence and proficiency. A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. Laschinger S, Medves J, Pulling C, et al. The learning environment should closely mimic real-world applications. An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. Check the patency of the patients right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA. Groups of fewer than four students dont allow for optimal collaboration. Prehosp Emerg Care. Patients with DKA require fluid resuscitation to restore circulatory volume, clear ketones, correct electrolyte abnormalities and increase renal perfusion. Conclusion: Our DKA simulator is a new tool whose objective is the training in a severe, frequent and complex situation, and can be used to improve the approach made by the junior physicians to the real diabetic . For diabetic assessment involving DKA, staging may include the use of a container with a small amount of acetone placed near the manikin because many students may not know what acetone smells like but will expect to smell something. As this is a PBL session, the trainees are not given any references. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. For similar reasons, we do not believe a videotaped session will keep the students attention as much as these live simulator sessions. DO NOT perform any examination or procedure on patients based purely on the content of these videos. - Associated symptoms 03:04 Administer oxygen to all critically unwell patients during yourinitialassessment. This simulation session therefore aims to make the case come alive, and show this known case in a clinical context. "Never doubt that a small group of thoughtful, committed citizens can change the world. The instructors have to appreciate that the trainees participating in this simulation have not seen a diabetic patient in either a ward or ER, but that they have knowledge of the underlying physiology. A fixed-rate intravenous insulin infusion should be commenced initially to suppress ketogenesis, reduce blood glucose levels and address electrolyte disturbances. I assigned true to life parking codes, and added some extra parking for the superfluous US Express AI. Make sure thepatientsnotes,observationchartandprescriptionchartare easily accessible. TikTok: https://www.tiktok.com/@geekymedics It was developed for anesthesiology resident physicians with some background knowledge and experience caring for critically ill patients. your express consent. - Severity 05:32 The trainees have had background knowledge of biochemistry because they had completed the PBL case. Using your thumbs, slightly open the mouth by downward displacement of the chin. We also show them IV bags containing saline and Ringers lactate, as well as show them IV infusion sets. Development of simulation scenarios for an adolescent patient with diabetic ketoacidosis. Over the years, some groups happened to have the simulation session before the completion of the theoretical PBL session. Twitter: http://www.twitter.com/geekymedics We then start the DKA state. See Appendix D, Supplemental Digital Content 4, https://links.lww.com/SIH/A4. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. As individuals with uncontrolled type I . opioids, sedatives, anxiolytics, insulin, oral hypoglycaemic medications). The main purpose of the simulation is to draw a line from the theoretical, boring biochemistry to the clinical manifestations. A number of key modifiers are described that allow for the adjustment of case . The patient synopsis should include such standard aspects as age, sex, ethnicity, medical history, medications and allergies. These simulation sessions seem to work because the medical students do have prior knowledge. For example, if a student is to run a diabetic emergency in an extended living facility, the room should be staged with the appropriate bed, linens and medical equipment, and include personal artifacts and memorabilia normally found in such environments. - Examples 05:45 Place one hand on the patients forehead and the other under the chin. The impetus for creating and implementing the high-fidelity diabetic ketoacidosis (DKA) simulation was based on a needs assessment and reviewing of undergraduate nursing students' examination statistics in a second semester medical-surgical course. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. Other details are also important, including descriptions regarding patient language skill, social history, socioeconomic history, family history, religious practices or beliefs pertinent to treatment, and descriptive signs and symptoms. If an infection is suspected, IV antibioticsshould be administered as soon as possible. - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ This is an important period, as this is where the students see the theoretical concept (metabolic acidosis), come to life as for instance large tidal volumes. Stage 3: Ongoing management and monitoring of DKA 1 hour after initiation of treatment. Experience has shown that the more experienced the provider, the more detailed the environmental and manikin staging should be, because providers are trained to take in and interpret visual cues as indicators of patient status. Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus, most common in patients with type 1 diabetes in particular due to a deficiency or absence of insulin [1].. Review the patientscurrent medicationsand check any regular medications areprescribed appropriately. Trainee will appropriately request assistance and use available resources. 5. The required potassium replacement varies greatly. Chapters: We do point out the blood pressure (BP) cuff, but these medical students in their first year do not really need to know how the BP values are generated, they need to understand the origin and therapy for the low blood pressure. An hour was . Immersive simulations are mentally exhausting because they create an intense and stressful atmosphere requiring the learner to work outside their comfort zone. Because of this consciousness status, it is very difficult to obtain information of cardiovascular, pulmonary, renal, hepatic, endocrine, hematology, or coagulation status other than uncontrolled diabetes. Revisit history taking to explore relevant medical history and identify any precipitating factors for DKA. Could we not just do this as a large group session to all 160 students (versus 20 1-hour sessions to groups of eight students)? After initial insulin therapy has reduced plasma blood glucose levels (e.g. An oxygen mask is also demonstrated as an alternative device, as these early trainees had mostly not yet seen any of these devices. >> Patterson PD, Weaver M, Frank R, et al. Deteriorationshould be recognised quickly and acted upon immediately. MassBay EMS Program Integrates Training for Dogs, Heat Waves Are Killing More LA Homeless People. SimMan Nursing Scenarios Software. The main goal is to establish a safe learning environment for the learner [9, 13 . NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA. It involves a facilitating instructor, a small learner group and conceptual aspects of environmental and manikin staging to provide sensory cues. We have 18 to 20 PBL groups for an hour each in the week after their PBL DKA session. Conclusions This technical report describes the design and implementation of a simulation scenario on DKA for emergency medicine trainees. Moses Lake (WA) Fire Department Gets $3.3M Grant for more Firefighters, Woman Who Crashed into Responders, Killing PA Firefighter, Gets Prison, Three Apparent Gas Explosions at San Bernardino (CA) Mountain Homes, Enid (OK) Fire Department Begins SWAT Medic Program to Assist Police, FDNY EMS Providers Win COVID-19-Linked Free Speech Lawsuit, Coronavirus Origins Still a Mystery Three Years into Pandemic. She was taken to the Emergency Department from her soccer game because she complained of nausea, extreme fatigue, mild disorientation, and blurred vision toward the end of the soccer match. <> Simulation provides a safe environment where learning is enhanced through the deliberate practice of skills and controlled management of a variety of clinical encounters. 4. Recognize the signs and symptoms of a patient presenting with diabetic ketoacidosis. insulin-dependent type 2 diabetes), Altered consciousness (e.g. The following scenarios are available for download and are designed to meet your multi-disciplinary nursing needs. 2. The instructor can also gauge the direction the debriefing session should follow or be alerted to possible problems or conflicts in treatment opinions. 2003;78:783788. Two abstracts related to sleepiness in the EMS workforce were presented at the National Association of EMS Physicians symposium in January. Urinary tract infections are a common DKA precipitant. Seek senior helpif the patient shows no signs of improvement or if you have any concerns. We have spent many hours debating whether the small group format was a waste of time. Trainee will increase knowledge of professional behaviors during the simulation. She tends to drink sugar containing fluids (soda) when she is thirsty, and she eats fast foods (cream-filled muffins) when she is hungry. The teaching of diabetic assessment and management, like many other medical emergencies, lends itself well to case-based simulation. The purpose of this simulation is to demonstrate the specific clinical signs of the patients with DKA, and the keys by which we recognize DKA in the early stages. The instructions to the facilitators suggest a series of structured, sequential questions to the students (starting at one end, involving each student in turn, and repeatedly cycling around the group.) Use an effectiveSBARR handoverto communicate the key information effectively to other medical staff. The Simulation Laboratory session follows after a completed PBL session, and is aimed at making the case come alive, while providing a clinical perspective to preclinical students. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned. If foreign material is present, attempt removal using suction. reduced air entry, coarse crackles) to screen for evidence of pneumonia. Vital Signs: BP, 90/30 mm Hg (ECG shows normal sinus rhythm); central venous pressure, 0 to 2 cm H. Lungs: All lung fields are clear to auscultation without wheeze or rhonchi, and the respiratory pattern is typical of Kussmaul breathing, ie, large deep tidal volumes and increased respiratory rate. The learning objectives follow the American College of Graduate Medical Education (ACGME) Core Compentencies. Diabetic Ketoacidosis: An Emergency Medicine Simulation Scenario Simulation Scenario. The DKA simulation incorporates cue recognition, analysis of cues, generation of solutions, nursing interventions, and evaluation of outcomes, including effective communication and psychosocial concerns. From the Department of Anesthesiology, Pennsylvania State University College of Medicine, Hershey, PA. Dr. Murray is on the Speakers Bureau of METI, Sarasota, FL. Intubation lubricants can mimic drooling. See ourhistory taking guidesfor more details. As a next step, we will let one of the trainees talk to the patient, and prompt to ask medical questions such as previous medical issues or recent drug use for them to practice asking questions to generate a differential diagnosis (in this case, other causes for confusion).
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