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Introduction to simulation and debriefing Role of simulation in Emergency Department DKA Guidelines Shahzad B. Waheed, M.B.B.S, FRCPC, FAAP Assistant Professor Pediatric Critical Care Medicine. Outline. Introduction to simulation Demonstration of case
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Introduction to simulation and debriefing Role of simulation in Emergency Department DKA Guidelines Shahzad B. Waheed, M.B.B.S, FRCPC, FAAP Assistant Professor Pediatric Critical Care Medicine
Outline Introduction to simulation Demonstration of case Basic structure of Debriefing Diabetic Ketoacidosis
WhaWhat is Simulation • Simulation is a technique – not a technology • Use in Medical Education is to: “replace or amplify real experiences with guided experiences that evoke or replicate aspects of the real world.”
Definition • Simulation is defined as: “the artificial replication of sufficient components of a real-world situation to achieve certain goals.”
Simulation Based Medical Education • Simulation is a complimentary teaching method in the medical profession: “any educational activity that uses simultative aids to enhance medical educational message” “not to replace traditional methods, but to add to”
Why Simulation • 1999 Institute of Medicine report – • ‘to err is human’ • Highlighted the cognitive and technical errors in medical education • Patient safety became an important agenda item • Licensing and governing bodies challenged to improve physician confidence and patient safety
Ethical Theme of Simulation • Best standards of care and training • Error management and patient safety • Social justice – resource allocation “patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.”
Best Standards • Best standard for patient care • First do no harm to patients • Using patients as learning instruments is only justified when all approaches to minimize risks have been taken • Simulation allows trainees’ first encounters with real patients to be at higher technical and clinical proficiencies
Best Standards • Best standard for education • Responsibility of educators to provide clinicians with best training • Best standard for evaluation • Traditional evaluation focused on cognitive domain • With simulation can assess attitudinal and psychomotor as well
Error management Even with supervision it is inevitable that trainees cause preventable injuries In clinical setting errors must be stopped promptly In simulation errors may be allowed to progress Errors can occur at any level in medical education
Social Justice • Basic principle of distributive justice states: • Citizens equally share the risks of medical innovation, research and practice training • Most teaching institutions are urban and provide disproportionate care to the poor and under privileged • SBME may help equilibrate this imbalance
How could we use it To improve procedural and surgical skills Helps in improving communication Can be used to diagnose deficiencies in team management of critical care issues Can be used to help assess competency
Reviewed 40 consecutive charts in preceding 6 months • Intervention was a instruction of LP on manikin and proforma • Prospectively reviewed 25 next consecutive patient charts • Findings: • 4/12 clinical markers improved to 12/12 (p<0.01) • Improved charting • Change in behavior of junior staff • No change in % of traumatic taps
Cap Gas: • pH 7.05, pCO2 18, pO260 HCO3 3 BE -12 • Blood glucose is 35mmol/L
50 units of regular insulin in 50 cc of Normal Saline Start insulin at 0.1 unit/kg/hr If Patient weight is 12 kg therefore you need to run at 1.2 cc/hr
Cap Gas: • pH 7.05, pCO2 18, pO2 60 HCO3 3 BE -12 • Blood glucose is 35mmol/L
Emotional energy • Clarify what you want to achieve during the debrief / ground rules How do you feel now? What was it like in the scenario? Did it feel realistic? Basic Structure of Debriefing Venting
Summary of the events – hot seat / leader • Chronological order • Original problems, assessment, treatments “Can you summarise the events of the scenario and what you did” Pull in the rest of the group Descriptive Phase
Participants analyse the events in the scenario • key CRM principles & medical / technical aspects • Any ‘golden moments’ • Identify strengths, then weaknesses ‘’What did you do well in this scenario – why?’’ ‘’Anything you would you like to do Analytical Phase
Generalising what they have learnt to the next scenario. • Generalising to the workplace in the future. “Have you taken something new away from the scenario?” “Will this change any aspect of your practice at work tomorrow?” “What have you learnt?” Generalisation
Diabetic Ketoacidosis ShAhZad B. Waheed M.B.B.S,FRCPC,FAAP Assistant Professor Pediatric Critical care medicine
Objectives Definition Epidemiology Pathophysiology Risk Factors Complications Treatment Prevention Conclusion
Newfoundland and Labrador has one of the highest rates of Type I diabetes worldwide. Newhook et al Pediatric Diabetes 2008
Pediatrics 2008;121(5):e1258–66 Pediatric Diabetes 2006;7(2):101–7 Arch Dis Child2004;89(2):188–94 Diabetologia 2001;44(Suppl3):B75–80
JAMA 2002;287(19):2511–8. J Pediatr 2001;139(2):197–203
N Engl J Med 2001;344(4):264–9 Arch Dis Child 2001;85(1):16–22
Absolute Potassium Depletion • Serum potassium may be normal to high initially • Add potassium when K< 5 and with urination • K >5.5 – no potassium in IVF • K 4.5 – 5.5 – 20 meq/L K+ • K <4.5 – 40 meq/L K+
