The use of a simulated, evolving case scenario was an effective method of exposing nursing students to complex patient care. Abstract Introduction: This simulation on diabetic ketoacidosis (DKA) in the obstetric population presents learners with one of the more commonly encountered etiologies of critical illness in the pregnant patient. Virtual patient simulation (VPS) is an interactive computer simulation that recreates real-world scenarios with the objectives of training, education, and assessment for health care providers [].Virtual simulation has been used extensively to adapt nursing education to the COVID-19 pandemic context [], such as social distancing and/or confinement. We ask the trainee why the blood pressure is so low or heart rate is so high, and how we should treat it. 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. The file explaining the session is sent to instructors 1 week before the sessions. - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ This environment doesnt allow the student to identify presentation cues, be active in their own learning or apply their skills without endangering the lives of patients.(2). She Died the Next Day. type 1 diabetes) Complete insulin insensitivity (e.g. Example: If the provider immediately evaluates blood glucose, then the reading will display 45 mg/dL. Emergency medical services workLife characteristics contribute to clinically significant excessive daytime sleepiness. See our blood glucose measurement guide for more details. Works with Traffic 2005, but . 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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. The instructor should have visual access via one-way windows or cameras. See ourCXR interpretation guidefor more details. A collection of communication skills guides, for common OSCE scenarios, including history taking and information giving. 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. tall tented T waves in hyperkalaemia). Does the patient need a referral toHDU/ICU? See ourhistory taking guidesfor more details. A pre-briefing session is conducted prior to the start of the simulation scenario. Measure the patients capillary blood glucose and ketone levels to confirm the diagnosis and guide the management of DKA. Review the patientscurrent medicationsand check any regular medications areprescribed appropriately. The simulation session is also hosted as an interactive session. A collection of anatomy notes covering the key anatomy concepts that medical students need to learn. Depending on scenario complexity, team dynamic and treatment modalities, this simulation may take 1020 minutes. 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. Another example: At one minute into the scenario, the patient becomes unresponsive and their breathing becomes shallow. Its absolutely necessary to follow all immersive simulations with a positive, emotionally safe and nonjudgmental debriefing environment. Introduceyourselfto thepatientincluding yournameandrole. The normal reference range for fasting plasma glucose is 4.0 5.8 mmol/l. If the patient has clinical signs ofanaphylaxis(e.g. 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. 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.) PBL was introduced at our institution in 1995. If the patient has COPD and a history of CO2retention you should switch to aventuri maskas soon as possible andtitrate oxygen appropriately. Trainee will correlate the underlying pathophysiology with symptoms and signs as exhibited by the simulation session. Introduceyourselfto whoever has requested a review of the patient andlistencarefullyto their handover. Does the patient need reviewing by a specialist? Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ Several environments may be suitable for your classroom. 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. One of the key differences with the immersive simulation is that the instructor is absent from the simulation environment. We do have a wig that we place on the patient, but we do not try for full realism. For instance, if we mimicked the noise and traffic of a real emergency department, this would constitute excessive realism, and become a distraction to beginner medical students. Trainee will learn to collaborate with peers to decide on appropriate interventions, tests, and therapy. Please try after some time. Diabetic Ketoacidosis: An Emergency Medicine Simulation Scenario A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. A number of key modifiers are described that allow for the adjustment of case . The main purpose of the simulation is to draw a line from the theoretical, boring biochemistry to the clinical manifestations. If the patientloses consciousnessand there areno signs of lifeon assessment, put out acrash callandcommence CPR. After entering the environment, the student doesnt have the option of leaving the simulation until the learning objectives and performance measures are achieved. Because of the early stage (first year) of their medical careers, they have not yet seen vital sign monitoring, or patients, so these clinical aspects are introduced and emphasized. Simulation provides a safe environment where learning is enhanced through the deliberate practice of skills and controlled management of a variety of clinical encounters. It involves a facilitating instructor, a small learner group and conceptual aspects of environmental and manikin staging to provide sensory cues. Classroom Dynamics An hour was . The learning environment should closely mimic real-world applications. Diabetic Ketoacidosis (DKA) Clinical Pathway Emergency Department | Children's Hospital of Philadelphia NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. We introduce the Simulation Laboratory and the Simulator, and demonstrate: pulses, eyes blinking, pupil constriction, gas moves in and out of mouth (place hand over mouth), chest moves up and down. Make sure thepatientsnotes,observationchartandprescriptionchartare easily accessible. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180. Review the patients drug chart for medications which may cause a reduced level of consciousness (e.g. It may be necessary toexposethe patient during your assessment: remember to prioritise patient dignity and conservation of body heat. - Onset 01:48 Deteriorationshould be recognised quickly and acted upon immediately. Inspect theairwayfor obviousobstruction. You could also ask a student to smear a small amount of acetone on a piece of glass to see how volatile it is, helping them understand why its being exhaled by the DKA patient. Refer to your local guidelines which should provide a clear protocol for the management of DKA. The faculty member/course coordinator of Simulation Design DOI 10.7759/cureus.1286. You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate. J Nurs Educ. The instructors role is to facilitate active learning through a combination of learning styles. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. You might also be interested in our awesome bank of 700+ OSCE Stations. Categories: Emergency Medicine, Medical Education Keywords: diabetic ketoacidosis, simulation, expertise, emergency medicine . The diabetes with DKA clinical pathway is a detailed plan of the course of care for pediatric patients seen in the emergency department with diabetic ketoacidosis. Supplemental digital content is available for this article. >> Fernandez AR, Mac Crawford J, Pennell ML, et al. Section snippets . 1 Potassium losses occurring both before and during treatment of DKA must be replaced. The patient was placed in the supine position and was a little confused as well as drowsy but at times had a good verbal response (Glasgow Coma Scale 15/15). We are looking for declaration of DKA and request for pathway. If the patient isunconsciousorunresponsive, start thebasic life support(BLS)algorithmas per resuscitation guidelines. There are several causes of DKA, which we remember by the "five I's". A collection of free medical student quizzes to put your medical and surgical knowledge to the test! Review the patientsoxygen saturation(SpO2): Auscultate the chest to screen for evidence of respiratory pathology (e.g. Therefore, the session is divided into four sections of 15 minutes each, so that the facilitator is constantly aware of being on time (or not), even after the first 15 minutes period. Use an effectiveSBARR handoverto communicate the key information effectively to other medical staff. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment. Typically potassium levels should be maintained between 4.0 5.5 mmol/L and close monitoring is required. Note that if-thens must also include negative patient outcomes for when the provider doesnt take appropriate action. Competency-based medical education has seen widespread adoption in the field along with ongoing work in the areas of . 2011;15:108109. Are any further assessments or interventions required? This typically involves the use of anon-rebreathe maskwith an oxygen flow rate of15L. Wolters Kluwer Health Medical simulation technology is a powerful tool for training physicians but papers dealing with DKA simulators are scarce. It involves working through the following steps: Each stage of the ABCDE approach involvesclinicalassessment,investigationsandinterventions. She began experiencing progressively worsening thirst, increased appetite, and excessively increased urination. angioedema, rash) commence appropriate treatment as discussed in ouranaphylaxis guide. 2. This article originally appeared in March 2011 JEMS as Diabetes Demonstration: Simulation-based learning works best., Simulation Training Ideal for Diabetic Patients, CMS Begins Reprocessing Retroactive Payments, Documents Detail EMTs Failure to Aid Tyre Nichols, New Course Lets Bystanders Be the Help Until Help Arrives, All Paramedic Recruits in New Castle County (DE) Obtain NRP Certification, International Prehospital Medicine Institute Literature Review, March 2023. 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. Urinary tract infections are a common DKA precipitant. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. Case-based simulation should include two to three broad-focus objectives, as well as 1020 specific performance measures that the student should accomplish. To read Pages full Research Review column, visit www.jems.com/patient-care. The patient synopsis should include such standard aspects as age, sex, ethnicity, medical history, medications and allergies. The facilitator guides the group only when necessary. endobj We now provide the students with handouts of the data to save time and provide consistency. Surgical dressings and imitation blood can support medical history. 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. www.cdc.gov/diabetes/statistics/prev/national/. - PSA Question Pack: https://geekymedics.com/psa-question-bank/ Her medical, social, and family histories are not clear at the time of admission to the emergency department. Instructors should write a case study for the simulation before the session. Simulation Scenario for Anesthesia Providers Clark Obr, MD*, Anthony Mueller, MD *Corresponding author: clark-obr@uiowa.edu Abstract Introduction: This simulation on diabetic ketoacidosis (DKA) in . 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. 3. They have had no clinical exposure or any clinical experience. After the initial treatment is initiated, by showing a simulated urine and blood, and by getting them to smell ketones, we can enable the trainee to confirm the diagnosis of DKA. We demonstrate to the trainees the significant changes on the monitors by asking them to point out any changes on the simulator (clinical examination) and the vital signs (monitor parameters). 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. The scenario would include an if-then algorithm. Before trainees arrival into the simulation area, the simulator is already preprogrammed for DKA. reduced air entry, coarse crackles) to screen for evidence of pneumonia. When a group treatment decision is made that would be contraindicated or harmful to the patient, the instructor can redirect the learner group while maintaining an atmosphere inclined toward independent thinking. Centers for Disease Control and Prevention. Inspect for evidence of infection on the skin (e.g. Schneider Sarver PA, Senczakowicz EA, Slovensky BM. The Theory You may search for similar articles that contain these same keywords or you may Keywords: diabetic ketoacidosis, simulation, expertise, emergency medicine Introduction Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus, most . Nandate, Koichiro MD, PhD; Abola, Ramon MD; Murray, W Bosseau MB; Whitfield, Carol PhD; Lang, Charles PhD; Sinz, Elizabeth MD. I assigned true to life parking codes, and added some extra parking for the superfluous US Express AI. A patient presenting with altered level of consciousness and a blood sugar level below 80 mg/dL should be considered hypoglycemic, and treatment modalities should be consistent with those for a diabetic patient. SimMan offers you the ability to provide simulation education to challenge and test your students clinical and decision-making skills during realistic patient care scenarios. Clearly communicate how often would you like the patients observations relayed to you by other staff members. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. Manikin staging can provide strong cues. Intubation lubricants can mimic drooling. diagnosis of DKA Trigger 3, ABG show acidosis and high BM and normal potassium. A fixed-rate intravenous insulin infusion should be commenced initially to suppress ketogenesis, reduce blood glucose levels and address electrolyte disturbances. Well done, youve now stabilised the patient and theyre doing much better. Therefore, we have to emphasize the importance of airway, breathing, and circulation in the very sick patient in any clinical setting. The use of case-based simulation, although more complicated and time consuming for the instructor, immerses the students in the subject matter. Invasive monitors, including a left radial intraarterial and a right subclavian IV catheter, were placed. - Site 01:12 She had developed nausea, extreme fatigue, mild disorientation, and blurred vision toward the end of the soccer match. Using your thumbs, slightly open the mouth by downward displacement of the chin. Causes: Any situation arising in a diabetic that requires increased insulin without that demand being met can result in DKA. Mosby:Philadelphia. This style also doesnt mimic an actual scene, and a student may feel that treatment modalities and skills are performed at a slower rate than real-world applications. Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult. An integral part of a PBL session is for trainees to be able to navigate through huge literature bases. Capillary refill timemay be prolonged if the patient is hypovolaemic. Animated Lecture 1-6. modify the keyword list to augment your search. Target Learner Groups 3. The learning objectives follow the American College of Graduate Medical Education (ACGME) Core Compentencies. Indeed, it is the only thing that ever has.". His Heart Stopped On a Treadmill. A chest X-ray should not delay the emergency management of DKA. >> Patterson PD, Weaver M, Frank R, et al. - Character 02:14 In the meantime, you should re-assess and maintain the patients airway. Perform urinalysis and send the urine for culture if urinary tract infection is suspected. 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 . If fever is present, make sure to consider co-existing infection. Discuss the patients current clinical condition with aseniorclinicianusing anSBARR style handover. Keyword Highlighting Please write a single word answer in lowercase (this is an anti-spam measure). With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible. This video demonstrates how to use the SOCRATES acronym when taking a history of pain or other symptoms. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate. The simulators do not have rock steady vital sign values, and the students were unsure as to write down 121 or 122 mm Hg as the systolic blood pressure. Furthermore, we demonstrate and explain the basic parameters (ECG, SpO2, BP, capnography), using an interactive format of questions and answers, and encourage the group to observe the normal values. We found it more important to have the students full attention so that they could concentrate on concepts and not on menial tasks such as recording data. Should any changes be made to the current management of their underlying condition(s)? . MassBay EMS Program Integrates Training for Dogs, Heat Waves Are Killing More LA Homeless People. This allows us to get in touch for more details if required. 2008;6:278302. Diabetic ketoacidosis; Simulation training; Medical students. % The Theory Using the arterial line, the scenario becomes much more dynamic. This leads to hyperglycaemia, osmotic diuresis, and dehydration. <> We have been presenting Simulation Laboratory sessions to our preclinical medical students (first and second years). After the first voluntary session in 2006, feedback from the medical students indicated that they would like to receive this handout. There are just a few more things to do. 1. The choice of fluid type, rate of administration and volume should be tailored to the individual patient based upon their vital signs and electrolytes. This guide provides an overview of the recognition and immediate management of diabetic ketoacidosis (DKA)using an ABCDE approach. Scenarios. Prehosp Emerg Care. 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). 2. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction. As with the animated lecture, the simulation is strongly dependent on a focused case study. Diabetic Ketoacidosis: An Emergency Medicine Simulation Scenario Cureus. 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]). When erroneous treatment is delivered, the instructor can end the simulation. Animated lectures, however, must work within the framework of a focused case study, which requires increased preparation time. This is a 25-year-old woman with a medical history of diabetes medicated with 40 units insulin per day. Lets discuss your options. endobj 2017 May 29;9(5):e1286. Many of the preclinical students have never seen a real life clinical monitor or even an intravenous (IV) setup. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action. 2. Re-assessthe patient using theABCDE approachto identify any changes in their clinical condition and assess the effectiveness of your previous interventions. As this is a PBL session, the trainees are not given any references. We have spent many hours debating whether the small group format was a waste of time. Review thepatients notes,chartsandrecent investigation results. Trainee will recognize the need for therapy and suggest an appropriate therapy in a simulated environment. In this manner, the students have to apply their knowledge at the appropriate points during the progression of the scenario. Trainee will improve their understanding of clinical practice through reflective assessment of actual cases during the prior PBL sessions. 3. A patient with Type I diabetes will often have symptoms related to blood sugar imbalances that appear abruptly with polydipsia, polyuria, polyphagia and rapid weight loss. A traditional classroom lecture format allows for student participation but limits the instructors ability to create realistic situations. Interactive lecture/discussion with use of monitors that show the vital signs of the simulated patient on manikin. The HFS-DKA simulation teaching consisted of pre-briefing (an hour), running simulation (30 minutes) and debriefing (an hour) for the high-fidelity simulator using the Lardeal SIM man . DO NOT perform any examination or procedure on patients based purely on the content of these videos. Inspect the urine currently in the catheter bag and note its appearance (e.g. Prehosp Emerg Care. His Wife Gave Him CPR. The questionnaire for the assessment of the session is given in full in the web-based supplement (Appendix A, Supplemental Digital Content 1, https://links.lww.com/SIH/A1). "Never doubt that a small group of thoughtful, committed citizens can change the world. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. The following scenarios are available for download and are designed to meet your multi-disciplinary nursing needs. In other words, they do not have clinical experience, but they have clinical knowledge. Extremities: mild cyanosis, no clubbing or edema (verbalized by instructors); pulses equal, and symmetrical (elucidated by trainees). Cureus 9(5): e1286. A well-staged environment allows for greater student buy-in. DONT FORGET these 3 key components of the cardiovascular exam for your upcoming OSCEs Save this video to watch later and dont forget to follow Geeky Medics! 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. In keeping with the case study, as a treatment marker is reached, the instructor should place emphasis on physiological, pharmacological, environmental and psychosocial issues.
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