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Published August 2015. Diabetic ketoacidosis; Simulation training; Medical students. Section snippets . 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. They have had no clinical exposure or any clinical experience. 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. 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. Observe and discuss the effects of therapy in a mathematically modeled physiological simulator. His Wife Gave Him CPR. 4 0 obj Many of the preclinical students have never seen a real life clinical monitor or even an intravenous (IV) setup. Use an effectiveSBARR handoverto communicate the key information effectively to other medical staff. 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). 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. We have spent many hours debating whether the small group format was a waste of time. 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. Mosby:Philadelphia. 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. 2009;13:505511. Some error has occurred while processing your request. 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. Diabetic ketoacidosis (DKA) is a common, potentially lethal disease. The optimal number of simulation participants is four to seven individuals, depending on the case study objectives. In the final 10 minutes, we show how the patient has a good recovery after fluid replacement. The researchers found that long shift hours (24hrs), working overtime and marital/relationship stress were strongly correlated. 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 2003;78:783788. For similar reasons, we do not believe a videotaped session will keep the students attention as much as these live simulator sessions. DKA can develop within 24 hours and is potentially life threatening, requiring prompt recognition and therapeutic intervention. Cureus 9(5): e1286. J Nurs Educ. This is a combination of the modified traditional lecture within scenario-based learning. We also show them IV bags containing saline and Ringers lactate, as well as show them IV infusion sets. 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). - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ 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. Finally, we summarize the course and give them time for questions. Therefore, we have to emphasize the importance of airway, breathing, and circulation in the very sick patient in any clinical setting. opioids, sedatives, anxiolytics, insulin, oral hypoglycaemic medications). If the patient is confused you might be able to get a collateral history from staff or family members as appropriate. The students are in their basic science course. The normal reference range for fasting plasma glucose is 4.0 5.8 mmol/l. See ourfluid prescribing guidefor more details onresuscitation fluids. Typically potassium levels should be maintained between 4.0 5.5 mmol/L and close monitoring is required. Just place the BR2_KDCA file into your addons scenery folder: C:\\Program Files\\Microsoft Games\\Microsoft Flight Simulator X\\Addon Scenery\\Scenery. DOWNLOAD Diabetic Ketoacidosis By the end of this scenario, the learner will be able to: 1. Diabetic Ketoacidosis: An Emergency Medicine Simulation Scenario Cureus. Consider active re-warming techniques in patients with severe hypothermia. Groups of fewer than four students dont allow for optimal collaboration. The Theory A pre-briefing session is conducted prior to the start of the simulation scenario. 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. Trainee will be able to apply skills of communication with the simulated patient in a semiacute crisis to get sufficient important information for a final diagnosis. Review the patients drug chart for medications which may cause a reduced level of consciousness (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 60 minutes training time consists of four 15-minute sections divided as follows. DKA can be caused by either: Absolute insulin deficiency (e.g. If an obstruction is visible within the airway, use afingersweeporsuctionto remove it. >> Fernandez AR, Mac Crawford J, Pennell ML, et al. Facilitator to ask how often to measure BMs 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. Glycosuria leads to urinary losses of potassium through osmotic diuresis. If any obstruction is encountered, remove the tube and try the left nostril. There are several causes of DKA, which we remember by the "five I's". 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). 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. Please write a single word answer in lowercase (this is an anti-spam measure). The students are in their first year. 2007. Ziv A, Wolpe PR, Small SD, et al. 1. Questionswhich may need to be considered include: The next team of doctors on shift should bemade awareof any patient in their department who hasrecently deteriorated. Diabetes mellitus affects nearly 7.8% of the U.S. population, with approximately 510% of this group affected by Type I and 9095% by Type II.1 Diabetes is the most common type of endocrine disease and was the seventh leading underlying cause of death listed on death certificates in 2006. Available from: [. However, this turned out to be too slow, took too much time, and could not continuously demonstrate the direction of changes. %PDF-1.5 Centers for Disease Control and Prevention. A blood glucose level may already be available from earlier investigations (e.g. 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. For more information, please refer to our Privacy Policy. Cureus is on a mission to change the long-standing paradigm of medical publishing, where submitting research can be costly, complex and time-consuming. We do not use passive visualizing materials such as videotapes or DVD other than vital signs shown on the monitors. Review the patientsoxygen saturation(SpO2): Auscultate the chest to screen for evidence of respiratory pathology (e.g. The relationship between sleep, fatigue and patient and provider safety. Management of diabetic ketoacidosis in adults. Immersive Simulations You can check out our guide to using SOCRATES here: https://geekymedics.com/the-socrates-acronym-in-history-taking/ Circulating nurse in the emergency room (ER). A strong emphasis is placed on the focused, methodical examination of a specific medical problem and the decision-based treatment options available. 1. Trainee will increase knowledge of professional behaviors during the simulation. We give the history of the patient to the trainees. a simulation training session designed to acquaint emergency medicine residents with the presentation and management of diabetic ketoacidosis (DKA) through the use of simulation. General: Moaning, asking what has happening to her. If the patient is conscious, sit themuprightas this can also help with oxygenation. Advance the airway until it lies within the pharynx. The debriefing environment should be removed from the location where the simulation took place. 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. Healthcare Students' Psychological Well-Being in a Diabetic Ketoacidosis Simulation. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. Weight, Height: Not given, normal appearing (as per simulator) but has lost 20 lbs recently. In this case scenario, dehydration is one of the most serious immediate issues. Given 6 to 8 back-to-back sessions, it is critical that every session starts and ends on time! Strategies of high-performing paramedic educational programs. 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 video demonstrates how to use the SOCRATES acronym when taking a history of pain or other symptoms. Inspect for evidence of self-injection sites (e.g. 3. Categories: Emergency Medicine, Medical Education Keywords: diabetic ketoacidosis, simulation, expertise, emergency medicine . 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. 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. If you have any scenarios you would be willing to share with the simulation community, please forward them to me. areas of lipohypertrophy) if it is unclear if the patient is diabetic. The instructors never expect the trainees to exhibit full understanding of pathophysiology and skills in the treatment but do give them a few important points to understand the diagnosis and initial treatment of the patients with DKA. Both external and internal potassium balances are disturbed during the development and treatment of DKA. They have had no clinical exposure or any clinical experience. Conclusion 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. (1) According to Centers for Disease Control and Prevention (CDC), 223,619 deaths were attributed to diabetes in 2005. One of the key differences with the immersive simulation is that the instructor is absent from the simulation environment. If the patientloses consciousnessand there areno signs of lifeon assessment, put out acrash callandcommence CPR. 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. 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. Medical simulation technology is a powerful tool for training physicians but papers dealing with DKA simulators are scarce. }HyEf,#$/JSRU9+CF6k\'/z+i`[ 5JudK*Zly^g%[jCK)H[)Y=Qp0/r9o9HW_zF}pTzI~'|q.~:=Y T 9w! cloudy urine may indicate urinary tract infection). Consider any precipitating factors for the development of DKA and involve the diabetes team in the patients care. As the name says, this screen is used to graph and plot any parameter. Prehosp Emerg Care. Therefore, the same file is also sent to the participants before the session. www.cdc.gov/diabetes/statistics/prev/national/. This is a 25-year-old woman with a medical history of diabetes medicated with 40 units insulin per day. Regardless of the underlying cause of airway obstruction, seekimmediate expert supportfrom an anaesthetist and the emergency medical team (often referred to as the crash team). ABG, venepuncture). The authors of the second study reported that poor sleep quality (60% of respondents) and extreme fatigue (55% of respondents) are independently associated with safety risks on the job. The trainees have had background knowledge of biochemistry because they had completed the PBL case. DOI 10.7759/cureus.1286. Standardized patient as the voice of the simulator (or the simulation operator may play this role). It was developed for anesthesiology resident physicians with some background knowledge and experience caring for critically ill patients. Similar to a ward round, where the instructor would say: Come and listen to this patient with an aortic stenosis. type 1 diabetes), Complete insulin insensitivity (e.g. Trainee will recognize and interpret the clinical signs and symptoms and the typical history of a patient with DKA, as well as understand the major causative factors of DKA. - Severity 05:32 The simulation session is also hosted as an interactive session. 2 0 obj If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR. <>>> Below is a collection of donated scenarios for you to use or modify. You may need further help or advice from a senior staff member and you shouldnot delay seeking help if you have concerns about your patient. 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. A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. 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. Immersive simulations are mentally exhausting because they create an intense and stressful atmosphere requiring the learner to work outside their comfort zone. Assess the patients pulse and blood pressure: Inspect the patient from the end of the bed: they may appear drowsy, confused and/or clammy/pale. LYqC+pJ&6X4onfBT#?=R}.p8N3+Dk,P4tIgWB}-L'=8;_G >,K#.e89XnG'B~NtR The instructors role is to facilitate active learning through a combination of learning styles. Int J Evid Based Healthc. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. Refer to your local guidelines which should provide a clear protocol for the management of DKA. DY{Qb"(EgN$QI*%XN1F""0a5 Re-assessthe patient using theABCDE approachto identify any changes in their clinical condition and assess the effectiveness of your previous interventions. Urinary tract infections are a common DKA precipitant. Keyword Highlighting Its important to train and educate students of prehospital care on key indicators of a diabetic emergency. TheABCDEapproach can be used to perform a systematic assessment of a critically unwell patient. Join the Geeky Medics community: Case-based simulation should include two to three broad-focus objectives, as well as 1020 specific performance measures that the student should accomplish. . 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. endobj Blood sugar issues in the Type II diabetic will have a gradual onset, with diagnosis generally resulting from routine laboratory exams.(1). 3. DO NOT perform any examination or procedure on patients based purely on the content of these videos. and 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. Adds true to life parking codes and extra parking for AI. This allows us to get in touch for more details if required. Open the patients airwayusing ahead-tiltchin-lift manoeuvre: 1. There are just a few more things to do. 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. dq-]gX4 `L'u7myx) rpjf0z,.y`VMyx-&Ju`U0 On arrival to the ER, standard monitors (electrocardiogram [ECG] and pulse oximetry [SpO2]) and end-tidal carbon dioxide (ETCO2) concentration were placed, and the patient was given oxygen by nasal cannulae. 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. By joining Cureus, you agree to our If you have any scenarios you would be willing to share with the simulation community, please forward them . Does the patient need reviewing by a specialist? - Character 02:14 A collection of free medical student quizzes to put your medical and surgical knowledge to the test! In the meantime, you should re-assess and maintain the patients airway. 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). Margolis GS, Romer GA, Fernandez AR, et al. Antibiotics should be prescribed in keeping with local guidelines. We guide the group to suggest fluid. 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.. Given such a small group, the students indicated that they feel more involved than they would with a larger group (eg, the whole class.) The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction. Groups of more than seven may struggle with meeting objectives due to insufficient functional rolls. Instructors should write a case study for the simulation before the session. Much time was wasted explaining why it did not matter. 1. His Heart Stopped On a Treadmill. Works with Traffic 2005, but . Inspect theairwayfor obviousobstruction. Effectiveness of simulation on health profession students knowledge, skills, confidence and satisfaction. If an infection is suspected, IV antibioticsshould be administered as soon as possible. In this section, we have to help the trainee to institute definitive therapy based on the underlying biochemical abnormalities. Simulation provides a safe environment where learning is enhanced through the deliberate practice of skills and controlled management of a variety of clinical encounters. Available from: [, NICE guidelines. A collection of surgery revision notes covering key surgical topics. The patient synopsis should include such standard aspects as age, sex, ethnicity, medical history, medications and allergies. See Table 4 for a suggested standardized script. Twitter: http://www.twitter.com/geekymedics Simulation provides a safe environment where learning is enhanced through the deliberate practice of skills and controlled management of a variety of clinical encounters.