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. Trainee will correlate the underlying pathophysiology with symptoms and signs as exhibited by the simulation session. Scenarios. This is a 25-year-old woman with a medical history of diabetes medicated with 40 units insulin per day. Using the arterial line, the scenario becomes much more dynamic. Published August 2015. Lets discuss your options. 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. We used the Medical Education Technologies Inc. (METI) Human Patient Stimulator (HPS, METI Sarasoto, Fl). Properly interpret a venous blood gas (VBG) and basic metabolic panel in a patient presenting with diabetic ketoacidosis. If the patientloses consciousnessand there areno signs of lifeon assessment, put out acrash callandcommence CPR. Her medical, social, and family histories are not clear at the time of admission to the emergency department. 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. Diabetic ketoacidosis; Simulation training; Medical students. A traditional classroom lecture format allows for student participation but limits the instructors ability to create realistic situations. The use of case-based simulation, although more complicated and time consuming for the instructor, immerses the students in the subject matter. 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). This field is for validation purposes and should be left unchanged. Observe and discuss the effects of therapy in a mathematically modeled physiological simulator. During the debriefing process that follows the simulation, well-balanced performance measures will guide feedback toward accomplished tasks and may illustrate existing decision-making, behavioral or technical skill deficits. DKA can be caused by either: Absolute insulin deficiency (e.g. reduced air entry, coarse crackles) to screen for evidence of pneumonia. We also show them IV bags containing saline and Ringers lactate, as well as show them IV infusion sets. The required potassium replacement varies greatly. DO NOT perform any examination or procedure on patients based purely on the content of these videos. - Medical Finals Question Pack: https://geekymedics.com/medical-student-finals-questions/ Clinical Simulation in Nursing, Volume 39, 2020, pp. Refer to your local guidelines for further details. Clearly communicate how often would you like the patients observations relayed to you by other staff members. 4. 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. your express consent. Review the patients drug chart for medications which may cause a reduced level of consciousness (e.g. 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. tall tented T waves in hyperkalaemia). 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. Recognize the signs and symptoms of a patient presenting with diabetic ketoacidosis. Open the patients mouth to ensure there is no foreign material that may be pushed into the larynx. Medical simulation technology is a powerful tool for training physicians but papers dealing with DKA simulators are scarce. A number of key modifiers are described that allow for the adjustment of case . As this is a value-added session that demonstrates new concepts, such as the vital signs on a clinical monitor, there are no assessment instruments to measure gaining of understanding. Advance the airway until it lies within the pharynx. To read Pages full Research Review column, visit www.jems.com/patient-care. to maintaining your privacy and will not share your personal information without doi: 10.7759/cureus.1286. See ourintravenous cannulation guidefor more details. Twitter: http://www.twitter.com/geekymedics 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. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. If the patient is conscious, sit themuprightas this can also help with oxygenation. In the final 10 minutes, we show how the patient has a good recovery after fluid replacement. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction. The learning environment should closely mimic real-world applications. The students are in their first year. 3. - 700+ OSCE Stations: https://geekymedics.com/osce-stations/ VbQuX#R M21 Ask for anotherclinicalmemberofstafftoassistyou if possible. She is lethargic and slightly confused but can intermittently respond to questions. 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. In some cases, normal saline with additional potassium is required to prevent overcorrection of serum potassium levels which would otherwise result in hypokalaemia. to below 12 mmol/L) an infusion containing normal saline and 5% dextrose is typically commenced to prevent the development of hypoglycaemia, whilst allowing insulin therapy to continue to suppress ketogenesis and reduce serum electrolyte concentrations. 2. The DKA simulation incorporates cue recognition, analysis of cues, generation of solutions, nursing interventions, and evaluation of outcomes, including effective communication and psychosocial concerns. 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. However, this leads to confusion. Revisit history taking to explore relevant medical history and identify any precipitating factors for DKA. Use washable, non-toxic paints to imitate various body emissions. 4 0 obj 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. DOI 10.7759/cureus.1286. 2011;15:108109. If the patient isunconsciousorunresponsive, start thebasic life support(BLS)algorithmas per resuscitation guidelines. Using your thumbs, slightly open the mouth by downward displacement of the chin. 2 The evaluation of potassium deficits is complicated by potassium exit from . Scenario in a Nutshell Diabetic ketoacidosis (DKA) in pregnancy. If you have any scenarios you would be willing to share with the simulation community, please forward them to me. The students have acquired all the applicable theoretical knowledge of the case during the previous multiday PBL sessions. However, we should not spend too much time on (not become distracted with) explaining unfamiliar monitors for the present trainees, such as central venous pressure or ETCO2 concentration. PA EMT Said COVID Patient Didnt Need to Go to the Hospital. Place one hand on the patients forehead and the other under the chin. Please write a single word answer in lowercase (this is an anti-spam measure). Manikin staging can provide strong cues. 3. A collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. Clearlydocument your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patients response. Measure the patients capillary blood glucose and ketone levels to confirm the diagnosis and guide the management of DKA. 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. 1. A list of the requirements (monitors, props, and others) is given in Tables 2 and 3, as well as in the web supplement (Appendix C, Supplemental Digital Content 3, https://links.lww.com/SIH/A3). Weight, Height: Not given, normal appearing (as per simulator) but has lost 20 lbs recently. 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. - Radiation 02:45 Cureus 9(5): e1286. Case-based simulation should include two to three broad-focus objectives, as well as 1020 specific performance measures that the student should accomplish. Use blankets to re-warm patients who are mild to moderately hypothermic. Makeup may be used to depict gender, hollow eyes and cheeks, produce pallor or display bruises and scars. Well done, youve now stabilised the patient and theyre doing much better. DKA can develop within 24 hours and is potentially life threatening, requiring prompt recognition and therapeutic intervention. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. An individual student can get an immediate answer to a question, the facilitator can see puzzled expressions on faces, and the PBL group could get answers that they could not get during their prior PBL group discussions. Nandate, Koichiro MD, PhD; Abola, Ramon MD; Murray, W Bosseau MB; Whitfield, Carol PhD; Lang, Charles PhD; Sinz, Elizabeth MD. A simulation training session is described designed to acquaint emergency medicine residents with the presentation and management of diabetic ketoacidosis through the use of simulation. We have been presenting Simulation Laboratory sessions to our preclinical medical students (first and second years). Data is temporarily unavailable. . "Never doubt that a small group of thoughtful, committed citizens can change the world. The lecture allows for understanding of concepts prior to action, and instructor feedback is immediate. - PSA Question Pack: https://geekymedics.com/psa-question-bank/ She began experiencing progressively worsening thirst, increased appetite, and excessively increased urination. Simulation provides a safe environment where learning is enhanced through the deliberate practice of skills and controlled management of a variety of clinical encounters. 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. 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. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. Initially, we used a blood pressure cuff to generate the blood pressure values. 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. Tilt the forehead back whilst lifting the chin forwards to extend the neck. This session provides additional clinical support material for the theoretical PBL session. If you'd like to support us and get something great in return, check out our awesome products: You don't need to tell us which article this feedback relates to, as we automatically capture that information for you. If the patient is suspected to have sufferedsignificanttraumawith potential spinal involvement, perform ajaw-thrustrather than a head-tilt chin-lift manoeuvre: 2. Stage 2: Emergency management of DKA and consideration of abnormal CTG. Works with Traffic 2005, but . Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. Extremities: mild cyanosis, no clubbing or edema (verbalized by instructors); pulses equal, and symmetrical (elucidated by trainees). 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). (1) According to Centers for Disease Control and Prevention (CDC), 223,619 deaths were attributed to diabetes in 2005. The main purpose of the simulation is to draw a line from the theoretical, boring biochemistry to the clinical manifestations. Stage 1: Initial assessment of acutely unwell pregnant woman and diagnosis of DKA. In keeping with the case study, as a treatment marker is reached, the instructor should place emphasis on physiological, pharmacological, environmental and psychosocial issues. An arterial blood gas (ABG) can provide lots of useful information to guide management including: A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. 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. This typically involves the use of anon-rebreathe maskwith an oxygen flow rate of15L. Categories: Emergency Medicine, Medical Education Keywords: diabetic ketoacidosis, simulation, expertise, emergency medicine . DKA can develop within 24 hours and is potentially life threatening, requiring prompt recognition and therapeutic intervention. We have 18 to 20 PBL groups for an hour each in the week after their PBL DKA session. Discuss the patients current clinical condition with aseniorclinicianusing anSBARR style handover. Make sure thepatientsnotes,observationchartandprescriptionchartare easily accessible. In the context of DKA, a patients consciousness level may be reduced. 3. - Introduction 00:00 Its important to train and educate students of prehospital care on key indicators of a diabetic emergency. 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). Surgical dressings and imitation blood can support medical history. We are looking for declaration of DKA and request for pathway. An hour was . Open the patients airwayusing ahead-tiltchin-lift manoeuvre: 1. It was developed for anesthesiology resident physicians with some background knowledge and experience caring for critically ill patients. 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)? Initially, we required the students to write down the vital signs. As this is a PBL session, the trainees are not given any references. Data Description All the product records are stored at /user/spark/dataset/retail_db/products All the category records are stored at /user/spark/dataset /ret. Mosby:Philadelphia. 5. See our blood glucose measurement guide for more details. Debriefing A comprehensive collection of medical revision notes that cover a broad range of clinical topics. The facilitator guides the group only when necessary. Refer to your local guidelines which should provide a clear protocol for the management of DKA. The choice of fluid type, rate of administration and volume should be tailored to the individual patient based upon their vital signs and electrolytes. It involves working through the following steps: Each stage of the ABCDE approach involvesclinicalassessment,investigationsandinterventions. . 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. - Timing 03:23 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. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible. 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). His Wife Gave Him CPR. The instructors role is to facilitate active learning through a combination of learning styles. You may be asked to review a patient with DKA due to confusion, reduced level of consciousness, tachycardia, hypotension and/or vomiting. Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing. #geekymedics #fyp #fypviral #studytok #medicalstudentuk #medtok #studytips #studytipsforstudents #medstudentuk #premed #medschoolfinals #shorts, Cardiovascular Exam Tips - DON'T FORGET these 3 things , Watch this video to find out the most COMMONLY FORGOTTEN components of the cardiovascular history! Save this video to help prepare for your upcoming OSCEs and dont forget to follow Geeky Medics! From the Department of Anesthesiology, Pennsylvania State University College of Medicine, Hershey, PA. Dr. Murray is on the Speakers Bureau of METI, Sarasota, FL. For similar reasons, we do not believe a videotaped session will keep the students attention as much as these live simulator sessions. 3 0 obj Glycosuria leads to urinary losses of potassium through osmotic diuresis. Instructors should write a case study for the simulation before the session. Make sure to re-assess the patient after any intervention. If an obstruction is visible within the airway, use afingersweeporsuctionto remove it. The student group is given a short introduction into a closed simulation environment. Chapters: Example: If the provider immediately evaluates blood glucose, then the reading will display 45 mg/dL. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. DO NOT perform any examination or procedure on patients based purely on the content of these videos. If foreign material is present, attempt removal using suction. x]o ]?9kgq~:)?hE )R6!up}\<8||\]}Y~;xp~yQ$#4~djX&{n_m-]^K1/~/AD Hv 99evs,;8}8zwnhFxV.kf-V^? Immersive simulations are mentally exhausting because they create an intense and stressful atmosphere requiring the learner to work outside their comfort zone. areas of lipohypertrophy) if it is unclear if the patient is diabetic. You may search for similar articles that contain these same keywords or you may Just place the BR2_KDCA file into your addons scenery folder: C:\\Program Files\\Microsoft Games\\Microsoft Flight Simulator X\\Addon Scenery\\Scenery. 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. In this case scenario, dehydration is one of the most serious immediate issues. Re-assessthe patient using theABCDE approachto identify any changes in their clinical condition and assess the effectiveness of your previous interventions. The file explaining the session is sent to instructors 1 week before the sessions. *=NdL/c2XSJn8:I Jb8'.8>N*[L .hxw6afq40DX3c~>abt'Q,8y(BZu(vKBTufIR. The use of a simulated, evolving case scenario was an effective method of exposing nursing students to complex patient care. There are several causes of DKA, which we remember by the "five I's". 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. Animated lectures, however, must work within the framework of a focused case study, which requires increased preparation time. stream Schneider Sarver PA, Senczakowicz EA, Slovensky BM. If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR. 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. 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. Diabetic ketoacidosis (DKA) is a common, potentially lethal disease. 1. Section snippets . endobj It involves a facilitating instructor, a small learner group and conceptual aspects of environmental and manikin staging to provide sensory cues. Strategies of high-performing paramedic educational programs. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate. 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]). >> Fernandez AR, Mac Crawford J, Pennell ML, et al. Refer to your local guidelines for further details. Blood sugar issues in the Type II diabetic will have a gradual onset, with diagnosis generally resulting from routine laboratory exams.(1). confusion, coma), All critically unwell patients should have. Environment & Manikin Conclusion A collection of surgery revision notes covering key surgical topics. Marx JA, Hockberger RS, Walls RM. The simulation session is also hosted as an interactive session. Over the years, some groups happened to have the simulation session before the completion of the theoretical PBL session. 2008;6:278302. Initially, we had a white board available, but the temptation (and habits) were just too strong, and the simulator sessions tended to become one way lectures, rather than an interactive, 2 way discussion.. This is particularly important for core . Diabetic Ketoacidosis (DKA) Clinical Pathway Emergency Department | Children's Hospital of Philadelphia Simulation-based medical education: An ethical imperative. She had developed nausea, extreme fatigue, mild disorientation, and blurred vision toward the end of the soccer match. Wolters Kluwer Health Generaltipsfor applying anABCDEapproachin an emergency setting include: Acute scenarios typically begin with abriefhandoverfrom a member of thenursing staffincluding thepatients name,age,backgroundand thereasonthereviewhas been requested. 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. Keyword Highlighting Circulating nurse in the emergency room (ER). 2. I assigned true to life parking codes, and added some extra parking for the superfluous US Express AI. Some manikin models support a variety of human functions, such as capillary and facial cyanosis, facial sweating, foley catheter and IV placement, blood pressure generation, cardiac rhythms and abnormalities, defibrillation, cardioversion, external pacing and vital sign generation. 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. An animated lecture may be described as a pseudo-simulation environment. After the first voluntary session in 2006, feedback from the medical students indicated that they would like to receive this handout. Given 6 to 8 back-to-back sessions, it is critical that every session starts and ends on time! Feel the slow and tardy pulse, we consider these PBL sessions as an example of a Look here, see this use of a full human simulator in the hierarchy of learning strategies with a full human simulator (Table 1). The trainees have had background knowledge of biochemistry because they had completed the PBL case. Despite this increased calorie intake, she noticed an unexplained 20 lbs weight loss. The 60 minutes training time consists of four 15-minute sections divided as follows. GRAPH. Similar to a ward round, where the instructor would say: Come and listen to this patient with an aortic stenosis. Facilitator to ask how often to measure BMs Intubation lubricants can mimic drooling. Forty percent of respondents reported excessive daytime sleepiness. 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. If the provider starts an IV and gives dextrose, then the patients alertness will increase, respirations will normalize and repeated blood glucose will read 210 mg/dL over a two-minute interval. type 1 diabetes) Complete insulin insensitivity (e.g. 4. Instagram: https://instagram.com/geekymedics Trigger 4, Pathway 1l of saline required over 1hour and insulin infusion need prescribing and making up in 50ml syringe. A chest X-ray should not delay the emergency management of DKA. Prehosp Emerg Care. %PDF-1.5 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! See ourhistory taking guidesfor more details. The student group should be encouraged to collaborate on management options and to perform skills. This allows the learner group to make a psychological break from the patient and environment while beginning the reflection process. 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. If an infection is suspected, IV antibioticsshould be administered as soon as possible. Immersive Simulations Management of diabetic ketoacidosis in adults. It may be necessary toexposethe patient during your assessment: remember to prioritise patient dignity and conservation of body heat. Review the patientsoxygen saturation(SpO2): Auscultate the chest to screen for evidence of respiratory pathology (e.g. Below is a collection of donated scenarios for you to use or modify. 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. For instance, one of the questions is: Why is Tiffany dehydrated? There are several possible reasons and mechanisms (as outlined in Appendix B, fourth 15 minutes, Supplemental Digital Content 2, https://links.lww.com/SIH/A2), which the students can mention. Review the patientscurrent medicationsand check any regular medications areprescribed appropriately. 6. We ask the trainee why the blood pressure is so low or heart rate is so high, and how we should treat it. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. A strong emphasis is placed on the focused, methodical examination of a specific medical problem and the decision-based treatment options available. 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. Should any changes be made to the current management of their underlying condition(s)? The students are in their basic science course. (1), The assessment of a diabetic patient is best taught as a case-based simulation. A debriefing section with pre-established questions allows the instructor to review the main focus and performance measures with the student group. DOWNLOAD Diabetic Ketoacidosis By the end of this scenario, the learner will be able to: 1. An integral part of a PBL session is for trainees to be able to navigate through huge literature bases. Physician working in the emergency department. On the basis of the feedback from the students, they indicated that they believed the small group sessions are better.
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