Simulation – clinical cases



Simulation – clinical cases

Respiratory Pathophysiology Course (second-year medical students)

November, 2011

I. TITLE: Respiratory pathophysiology simulation cases (pneumothorax and pneumonia)

II. TARGET AUDIENCE: Medical students 3 months into second year. (Consider third-year medical students.)

III. LEARNING OBJECTIVES / GOALS

A. Goals:

- Experience and understand the initial medical assessment and initial treatment of patients with respiratory symptoms.

- Differentiate between various pathophysiologic mechanisms and how they cause respiratory symptoms.

B. Objectives: By the end of the one-hour simulation program, the students will be able to:

- Correlate pathophysiologic mechanisms (such as increasing pleural pressure) to the diagnosis and management of pneumothorax.

- Describe pathophysiologic consequences of lower respiratory tract infections (such as V/Q mismatch) and how they contribute to symptoms.

- Describe initial treatment strategies for specific respiratory conditions.

C. Critical actions checklist:

Case 1: Baseline:

1) Elicit H&P

2) Perform exam

3) Identify tachycardia

4) Identify relative hypoxemia

5) Provide supplemental oxygen

6) Identify improvement in oxygen saturation with supplemental oxygen

Case 1: Worsening:

1) Identify worsening tachycardia, hypotension, and hypoxemia

2) Order chest x-ray

3) Perform ABG

4) Consider intubation

5) Identify the most likely diagnosis

6) Consult Surgery and/or needle decompress chest and/or place chest tube

Case 1: Improvement:

1) Discuss whether further interventions need to be pursued (if needle decompression, consider chest tube).

2) Provide pain medication for chest tube.

Case 2: Baseline:

1) Elicit H&P

2) Perform exam

3) Identify hypoxemia

4) Identify tachycardia

5) Order EKG

Case 2: Worsening:

1) Order CXR

2) Order ABG

3) Consider intubation

4) Identify the most likely diagnosis

5) Start antibiotics.

Case 2: Stabilization:

1) Consider chest CT.

2) Call ICU

IV. ENVIRONMENT:

A. LAB SET-UP: Standard simulation room with either a one-way observation mirror through which faculty and staff operating the control panel/laptop with mannequin software can observe participants, or a camera (web-cam) for which the faculty and staff can observe the participants from behind a partition. Faculty and staff may speak “for” the mannequin through a microphone at the control panel which will sound from a speaker in or near the mannequin’s mouth, allowing the mannequin to “answer” participants’ questions. The simulation room itself is set up to resemble a standard Emergency Department bay in the first case, and a standard hospital room in the second case.

B. MANNEQUIN SET-UP: Standard simulation mannequin with the capacity to project multiple different physical exam findings (i.e., wheezing and/or crackles and/or normal exam on pulmonary auscultation.) Faculty and staff can affect the mannequin’s physical exam findings in real-time via the control panel.

C. PROPS:

- Bedside monitor with real-time reporting of vital signs.

If possible, can have the following props, but not necessary for preclinical medical students:

- Code / resuscitation cart stocked with standard code medications and equipment.

- Airway kit with laryngoscopes, endotracheal tubes, oral airways, carbon dioxide detectors.

- Medications: morphine, lorazepam, vasopressors, induction medications for intubation, antibiotics.

D. DISTRACTORS: N/A.

E. LOGISTICS: Students will be completing two sim cases in 1 hour. Each sim case will consist of a 3-5 minute intro (see case stem below), 10-15 minute scenario, and 15 minute debrief.

V. ACTORS / STAFF:

A. Simulation specialist or technician – acts as the “voice” of the mannequin at the control panel., using non-medical terminology and speaking using a vocabulary a lay patient may be expected to use.

B. One sim center faculty member/simulation specialist or technician – plays the role of the bedside nurse in both scenarios. Provides medications and relays test results. He/she will coordinate the simulation environment and assist with ensuring that the students move through the case(s) in a timely fashion and will start the debriefing session.

C. One pulmonary faculty member – provides the brief feedback at the end of the sim session(s) regarding students’ understanding of the underlying pathophysiologic mechanisms and how these mechanisms contributed to their understanding of and approach to the clinical scenario. The pulmonary faculty member should not focus on the specific clinical management of the patients, and should only discuss the clinical management as it relates to the pathophysiology of the case.

VI. CASE 1 SCENARIO and INSTRUCTORS’ NOTES: Case 1 –Pneumothorax; Emergency Department Scenario: Nelson Diaz

A. Case background (given freely to participants): Nelson Diaz is a 21 year old man with no significant past medical history presents to the Emergency Department complaining of shortness of breath that started earlier today. You are Emergency Medicine physicians and are the first health care providers to evaluate this patient. The patient has had his vitals taken and is hooked up to a heart rate and pulse oximetry monitor. His nurse is in the room with you as you evaluate the patient.

B. Background and briefing for facilitators / coordinators (NOT given to participants at any point): This simulation scenario involves a young man presenting with acute dyspnea. The students will evaluate the patient through a standard H&P format. Available ancillary information includes his complete vital signs (students must ask the nurse for them and then can be brought up on the bedside monitor), and the results of pertinent tests. A facilitator will play the role of the nurse and assist the students in moving through the H&P and initial evaluation in a timely fashion. This sim scenario should take 10-15 minutes to complete. Debriefing, with a focus on pathophysiologic mechanisms, will occur following the simulation for 15 minutes.

C. Case content: H&P should be elicited by students asking the patient and/or nurse question and/or requesting specific studies. Study results may be immediately available, delayed, or unable to be performed (i.e., “the MRI scanner is down”) at the discretion of the faculty.

History & Physical (must be requested and must be stated in as little medical terminology as possible):

- 21yo man with no known past medical history.

- Developed sudden onset shortness of breath while playing softball this afternoon.

- He was running to first base when he had acute shortness of breath and had to stop running.

- He had associated right-sided chest pain that was “sharp” in character.

- Nothing like this has ever happened before to him.

- The chest pain has increased since its onset, but the shortness of breath has gradually worsened.

Medications (must be requested):

- He takes no medications, supplements, OTCs.

Family history:

- Sister has mild asthma. Father has hypertension.

Social History (must be requested):

- He smoked cigarettes briefly from age 15-17, but not since (total ~1 pack-year history).

- He smokes marijuana occasionally, last use was last night.

- No other illicit drugs.

- He drinks 2-3 alcoholic drinks 2-3 nights a week and >5 alcoholic drinks every 1-2 weeks.

Review of Systems (must be requested):

- Neuro: No pertinent positives.

- HEENT: No pertinent positives.

- Cardiovascular: Continued, significant chest pain as above, otherwise no pertinent positives.

- Pulmonary: Dyspnea as above, otherwise no pertinent positives, including no antecedent or post-onset cough, wheezing, hoarseness.

- Renal / hepatic: No pertinent positives.

- Endocrine: No pertinent positives.

- Hematologic: No pertinent positives.

Physical Exam (must be performed—if some findings need to be verbalized due to the limitations of the mannequin, only tell them after the students attempt to perform the physical exam maneuver):

- General: Tall, thin, young man appearing to be his stated age. Sitting up on stretcher, using accessory muscles of respiration, speaking in short (but not one-word) sentences, looks to be in moderate respiratory distress.

- HEENT: Normal.

- Cardiovascular: S1S2 RR / tachycardia, no murmurs or extra heart sounds.

- Pulmonary: Absent breath sounds on the right, good air movement with no wheezing or crackles on the left. (If specifically requested – trachea is perhaps mildly deviated to the left).

- Abdomen: Normal.

- Extremities: Normal.

- Neurologic exam: Normal.

Studies (if requested):

- Labs: Normal.

- Peak-flow: Low-normal (~350L/s).

- Chest x-ray: Right-sided pneumothorax. [Image available in Appendix A]

- EKG: Sinus tachycardia, no ischemic changes.

- Chest CT: Right-sided pneumothorax, no PE, otherwise normal (no image).

D. Case progression: Table on next page –

|State |Patient status |Learner actions |Trigger to move to next state |

|Baseline |Uncomfortable appearing, speaking |Elicit H&P |H&P completed, or |

| |in short (not one-word) sentences,|Perform exam |studies / treatments ordered without performing physical |

| |tachycardic, absent breath sounds |Begin to formulate differential |exam, or |

| |at the right apex. |diagnosis and consider studies or |10-15 minutes. |

| | |treatments | |

| |HR 120s |If the students are not progressing, | |

| |BP 150/80 |the pt’s PMD can call overhead and ask| |

| |Sat 95% on RA |what is occurring with their | |

| |Sat 98% on 2L NC |patient—prompting the students to | |

| | |perform the parts of the H&P they are | |

| | |missing, etc. | |

|Worsening |Progressive dyspnea, speaking in |React to clinical worsening – consider|Diagnosis identified, and |

| |1-2 word sentences, worsened |CXR (if not already ordered) |physical exam performed, and |

| |tachycardia, obvious tracheal |Perform exam (if not already done) |appropriate treatment determined, or |

| |deviation. |Identify the most likely diagnosis |10-15 minutes. |

| | |Consult Surgery and/or needle | |

| |HR 150s |decompress chest and/or place chest |If diagnosis is not identified during this portion of the |

| |BP 100/60 |tube [may need facilitator prompting |scenario, facilitators may need to prompt the students to |

| |Sat 88% (on any FiO2) |for this action] |either perform an exam and/or pursue appropriate studies |

| | |If no procedures are to be performed |and/or interpret appropriate studies and/or treat the |

| |If asked for: |on the mannequins—a Time-Out can be |patient appropriately. |

| |ABG = pH 7.42 / PaCO2 37 / PaO2 73|called to talk through the procedure | |

| |(on any FiO2) |/ anatomical landmarks |If students fixate on an incorrect diagnosis and pursue a |

| | | |treatment plan that will not address his pneumothorax, go to|

| | | |stage 4. |

|Improvement |After decompression or chest tube |Discuss whether further interventions |Move to case 2. |

| |placement, he is much more |need to be pursued. | |

| |comfortable, less tachycardic, |Consider pain medication for chest | |

| |normotensive, speaking in full |tube. | |

| |sentences, but with pain at the | | |

| |chest tube site. | | |

| | | | |

| |HR 100, BP 120/80 | | |

| |Sat 97% (on any FiO2) | | |

|Wrong diagnosis / |Significant clinical worsening, |Identify that the patient is worsening|Correct diagnosis identified, and |

|wrong treatment |tachycardia, hypotension, |and that their diagnosis or treatment |Appropriate treatment determined. |

| |hypoxemia - but the pt will not |is not working. | |

| |die (as we do not want the |Reassess the situation and consider |If students remain fixated on the wrong diagnosis, |

| |debriefing to focus on how to deal|other assessments / interventions. |faciliators may need to intervene to help the group consider|

| |with the death of a patient). | |alternatives. |

| | | | |

| |HR 180-200s, BP 70/40 | |Go to stage 3 when this stage is complete. |

| |Sat 70% (on any FiO2) | | |

VII. CASE 2 SCENARIO and INSTRUCTORS’ NOTES: Case 2 – Pneumonia; Clinic Scenario: Else Fitz

A. Case background (given freely to participants): A 91 year old woman with a history of hypertension, diabetes, osteoporosis, and moderate dementia was admitted to the hospital after suffering a mechanical fall that resulted in a broken right femur. While in the hospital, she has been undergoing cardiac testing to determine her cardiac risk of proceeding to surgery. You are the physicians on-call during the night and you are called to evaluate the patient at 2AM by the patient’s nurse for decreasing oxygen saturation over the past few hours. The patient has had her vitals taken and is hooked up to a heart rate and pulse oximetry monitor. Her nurse is in the room with you as you evaluate the patient. Your attending physician is at home, but is available by pager should you need more assistance.

B. Background and briefing for facilitators / coordinators (NOT given to participants at any point): This simulation scenario involves a woman with multiple co-morbidities who has developed a new pneumonia (either hospital acquired or aspiration). The students will evaluate the patient through a standard H&P format, although the patient’s dementia will limit the interview portion – this is intentional, both to replicate a real-world occurrence (a patient who cannot provide his or her own history) and for time purposes (to minimize the time spent on the HPI to allow both cases 1 and 2 to be performed in an hour). Available ancillary information includes her hospital course (provided by the nurse), her complete vital signs (students must ask the nurse for them), heart rate / oxygen saturation (on the monitor), and the results of pertinent tests. A facilitator will play the role of the nurse and assist the students in moving through the H&P and initial evaluation in a timely fashion. This sim scenario should take 10-15 minutes to complete. Debriefing, with a focus on pathophysiologic mechanisms, will occur after the simulation and will last 15 minutes.

C. Case content: H&P should be elicited by students asking the patient and/or nurse question and/or requesting specific studies. Study results may be immediately available, delayed, or unable to be performed (i.e., “the MRI scanner is down”) at the discretion of the faculty.

History & Physical (must be requested):

- 91yo woman with hypertension, diabetes, osteoporosis, moderate dementia, and recent hip fracture.

- Patient is alert and oriented x self and “hospital”.

- She denies all symptoms.

Hospital course (may request from nurse):

- The patient has been in the hospital for two days undergoing cardiac testing.

- She was not on supplemental oxygen on admission, but late this afternoon she desaturated to the low 90%s on RA and was placed on 2L NC.

- Over the last several hours, her oxygen needs have increased and she is now on a 50% FM.

- The nurse has observed the patient coughing this evening, occasionally bringing up purulent, yellow-green sputum.

- The nurse also noted the patient was having trouble eating dinner with frequent coughing and choking while swallowing.

Medications (must be requested):

- HCTZ, amlodipine, atorvastatin, aspirin, calcium / vitamin D, metformin, acetaminophen, pantoprazole, and subcutaneous heparin.

Family history (must be requested):

- Her parents have passed away – the patient does not know the causes.

Social History (must be requested):

- She has no known smoking, alcohol or illicit drug use.

Review of Systems (must be requested; limited by patient’s dementia):

- Neuro: No pertinent positives.

- HEENT: No pertinent positives.

- Cardiovascular: No pertinent positives.

- Pulmonary: No pertinent positives, although as above the nurse has noted a productive cough, possible aspiration, and desaturation.

- Renal / hepatic: No pertinent positives.

- Endocrine: No pertinent positives.

- Hematologic: No pertinent positives.

Physical Exam (must be performed—if some findings need to be verbalized due to the limitations of the mannequin, only tell them after the students perform the physical exam maneuver):

- General: Thin, confused woman appearing her stated age. She is using accessory muscles of respiration and intermittently coughing during the interview / exam. She answers questions in short sentences.

- HEENT: Bitemporal wasting, otherwise normal.

- Cardiovascular: S1S2 RR / tachy, III/VI SEM, no extra heart sounds.

- Pulmonary: Decreased breath sounds at the left base with egophany and tactile fremitus, left mid-lung crackles, no wheezing, adequate air movement bilaterally.

- Abdomen: Normal.

- Extremities: Normal.

- Neurologic exam: Alert but only oriented x self and “hospital”. No focal motor deficits.

Studies (if requested):

- Labs (performed earlier that day): WBC 17.0 (90% polys, 5% bands), Hct 34%, platelets 200. Chem-7 normal.

- Chest x-ray: Left basilar opacity (consistent with pneumonia). [Image available in Appendix B]

- EKG: Sinus tachycardia, no ischemic changes.

- Chest CT: Left basilar consolidation, no PE, otherwise normal (no image).

D. Case progression: Table–

|State |Patient status |Learner actions |Trigger to move to next state |

|Baseline |Uncomfortable appearing, speaking |Elicit H&P |H&P completed, or |

| |in short sentences, tachycardic, |Perform exam |studies / treatments ordered without performing physical |

| |crackles on the right. |Begin to formulate differential |exam, or |

| | |diagnosis and consider studies or |10-15 minutes. |

| |HR 120s |treatments | |

| |BP 120/80 |If the students are not progressing on| |

| |Sat 92% on 50% FM |this, the pt’s PMD can call overhead | |

| | |and ask what is occurring with their | |

| | |patient—prompting the students to | |

| | |perform the parts of the H&P they are | |

| | |missing, etc. | |

|Worsening |Progressive dyspnea, speaking in |React to clinical worsening – consider|Diagnosis identified, and |

| |1-2 word sentences, worsened |CXR (if not already ordered) |physical exam performed, and |

| |tachycardia, increased frequency |Perform exam (if not already done) |appropriate treatment determined, or |

| |of coughing. |Identify the most likely diagnosis |10-15 minutes. |

| | |Start antibiotics. | |

| |HR 130s | |If diagnosis is not identified during this portion of the |

| |BP 100/60 | |scenario, facilitators may need to prompt the students to |

| |Sat 84% (on any FiO2) | |either perform an exam and/or pursue appropriate studies |

| | | |and/or interpret appropriate studies and/or treat the |

| |ABG = pH 7.44 / PaCO2 35 / PaO2 59| |patient appropriately. |

| |(on any FiO2) | | |

|Stabilization |After initiation of antibiotics |Discuss whether further interventions |Move to debrief. |

| |and administration of IVF, the |need to be pursued. | |

| |patient is less tachycardic and |Consider transfer to ICU. | |

| |slightly more comfortable. | | |

| | | | |

| |HR 120s | | |

| |BP 120/80 | | |

| |Sat 93% (on any FiO2) | | |

VIII. DEBRIEFING PLAN:

A. Method of debriefing: Group debriefing primarily facilitated by the pulmonary faculty member, with an emphasis on underlying pathophysiologic mechanisms and their relationship to the clinical signs and symptoms the patients experienced in each case. Video will not be reviewed. Independent support materials beyond class notes will not be distributed.

B. Questions to facilitate debriefing:

- Case 1 (pneumothorax): Key points include the pathophysiologic consequences of air in the pleural space.

- Why did he desaturate?

- Why did he become tachycardic?

- Why did his blood pressure drop with progressive accumulation of air in the pleural space?

- How did his physical exam findings correlate with his diagnosis of pneumothorax?

- Case 2 (pneumonia):

Key points include the pathophysiologic causes of and consequences of pneumonia.

- What are possible causes of her pneumonia? What pathophysiologic mechanisms are involved in the different potential causes of her pneumonia?

- What about her (and/or her clinical circumstances) predisposes her to develop a pneumonia?

- Why did her oxygen saturation decrease? What pathophysiologic mechanisms explain this?

- Why did her heart rate increase and her blood pressure decrease?

C. Materials to support debriefing and to support focus on pathophysiologic mechanisms:

- Case 1 (pneumothorax):

- BACKGROUND: The first case is of a man who presents with acute onset pleuritic chest pain, dypsnea, and hypoxemia due to a spontaneous pneumothorax. Participants should be able to identify the physical exam and radiologic findings associated with a simple pneumothorax and with a tension pneumothorax (what this patient ultimately develops.) Questions regarding physical exam findings should be addressed in the debriefing, and the rational for the presence of specific exam findings (i.e., a deviated trachea, absence of breath sounds, hyper-resonance, etc) should be explicitly related to the underlying pathophysiologic process of air in the pleural space causing mass effect. If the case does have tension physiology (hypotension, deviated trachea), then it must be stressed to students that not all pneumothoraces have tension physiology.

-PATHOPHYSIOLOGY: The accumulation of excessive air in the pleural space results in numerous pathophysiologic consequences, including mechanical uncoupling of the lung and the chest wall leading to altered respiratory pump function. Additionally, air in the pleural space causes a relative obstructive deficit, such that if one were to perform PFTs (which would be clinically inappropriate!) the FRC would be noted to be decreased (again, due to uncoupling of the lung and the chest wall.) Atelectasis (from lung collapse) results in shunt with impaired gas exchange and the lack of a response to supplemental oxygen (see the “pathophysiology” section for case 2 below for more on gas exchange and ABG interpretation.) The effect of expanding air in the pleural space on hemodynamics should also be emphasized and participants should discuss why the patient was progressively tachycardic and hypotensive throughout the case, until pleural decompression was obtained (specifically, the effects of increasing volume of pleural air on right-sided venous return [decreased] and cardiac out-put [decreased to decreased preload and increased afterload] should be explicitly discussed.)

- Case 2 (pneumonia):

- BACKGROUND: The second case is a woman who presents with a left lower lobe pneumonia. She has typical features of pneumonia, although it is unclear if she has community acquired or hospital acquired pneumonia. For Community-Acquired Pneumonia (CAP), partcipants should be able to identify common pathogens such as streptococcus pneumonia, haemophilus influenzae, mycoplasma pneumonia, legionella pneumophila, Chlamydia pneumoniae and viral pathogens. Appropriate antibiotic choices could include fluoroquinolones or beta-lactams. Empiric coverage would include a macrolide with a beta-lactam if the diagnosis of s. pneumoniae was not definite. For Hospital Acquired Pneumonia (HAP), participants should be able to identify common pathogens such as methicillin-resistant staph auereus, pseudomonas aeruginosa, klebsiella pneumoniae, escherichia coli, acinetobacter, and some community acquired organisms (specifically streptococcus pneumonia and haemophilus influenzae).

- PATHOPHYSIOLOGY: Participants should be able to list the potential causes (alveolar hypoventilation, V/Q mismatch, shunt, low PiO2, and diffusion abnormalities). Participants should also be able to calculate the alveolar-arterial oxygen gradient (DAaO2): PAO2 = PIO2 - PACO2/R. If they did not do this during the case, they should be encouraged to do so during debriefing and recognize that an elevated A-a gradient is due to either V/Q mismatch, shunt or diffusion abnormalities. As diffusion abnormalities typically do not occur at rest, this patient’s ABG likely represents V/Q mismatch. Only a trial of 100% oxygen could determine whether this patient had a predominant V/Q mismatch state (the PaO2 would increase) or a predominant shunt state (the PaO2 would not significantly increase). Participants should review the indications for treatment with supplemental oxygen to improve this baseline hypoxemia and prevent complications such as hypoxic pulmonary vasoconstriction and subsequent cor pulmonale.

IX. PILOT TESTING AND REVISIONS

A. Numbers of participants: Approximately 150 second-year medical students in the fall of 2011. This was one educational exercise within their 3week long course on Respiratory Pathophysiology.

B. Performance expectations / management mistakes: The majority of student groups were able to complete both cases with adequate time for debriefing. Students were generally able to diagnose and elect appropriate treatment for case 1 without significant delay or difficulty. Of note, these students had experienced a similar case of pneumothorax during their first week of first year of medical school and may have an easier time diagnosing this patient because of this.

An unexpected occurrence in case 2 was that despite the lack of information from the patient due to her dementia, the students continued to try to obtain a history from the patient. Additionally, despite the physical exam and chest x-ray findings, several groups were focused on pulmonary embolism as a diagnosis and there was confusion on the students’ part as to if pulmonary emboli can be visualized on chest plain films.

C. Evaluation form for participants: See Appendix C.

D. Preliminary outcomes: Preliminary student evaluations indicate that these simulation scenarios were well received by leaners. Specifically, on a 5 point Likert scale (with 1 being ‘most helpful’ and 5 being ‘not at all helpful), the simulation sessions scored 1.88 (for context, tutorial sessions scored 1.39 and pathology labs scored 1.93). With regard to qualitative data, open-ended student comments regarding the simulation sessions were universally positive, with the primary themes focusing on the interactivity and educational aspects of the scenarios.

X. Authors and affiliations:

- Jeremy B. Richards, M.D., M.A, Respiratory Pathophysiology Course Director at Harvard Medical School; Instructor in Medicine, Beth Israel Deaconess Medical Center, Shapiro Center for Education, and Harvard Medical School.

- Emily M. Hayden, M.D., M.H.P.E., Associate Director for Curricular Integration, Gilbert Program in Medical Simulation, Harvard Medical School; Director of Simulation Faculty Development, Division of Medical Simulation, Department of Emergency Medicine, and Core Faculty, MGH Learning Laboratory, Massachusetts General Hospital

APPENDIX A:

Case 1: Pneumothorax – chest x-ray:

[pic]

Image from the collection of Jeremy Richards, M.D., M.A.

APPENDIX B:

Case 2: Pneumonia – chest x-ray:

[pic]

Image from the collection of Jeremy Richards, M.D., M.A.

APPENDIX C:

1) How well did these simulation sessions achieve the learning objectives (1 = not at all, 9 = completely)?

1 . . . . . . . . . 2 . . . . . . . . . 3 . . . . . . . . . 4 . . . . . . . . . 5 . . . . . . . . . 6 . . . . . . . . . 7 . . . . . . . . . 8 . . . . . . . . . 9

Not at all Somewhat Completely

2) Did these simulation sessions (including the debriefing) reinforce the role of pathophysiologic mechanisms in respiratory disease?

1 . . . . . . . . . 2 . . . . . . . . . 3 . . . . . . . . . 4 . . . . . . . . . 5 . . . . . . . . . 6 . . . . . . . . . 7 . . . . . . . . . 8 . . . . . . . . . 9

Not at all Somewhat Completely

3) After completing these scenarios, do you feel more comfortable in approaching respiratory problems in a clinical setting?

1 . . . . . . . . . 2 . . . . . . . . . 3 . . . . . . . . . 4 . . . . . . . . . 5 . . . . . . . . . 6 . . . . . . . . . 7 . . . . . . . . . 8 . . . . . . . . . 9

Uncomfortable Somewhat more comfortable Much more comfortable

4) Was the faculty who led the debriefing session effective in emphasizing pathophysiologic mechanisms and how they relate to the patients’ clinical presentations?

1 . . . . . . . . . 2 . . . . . . . . . 3 . . . . . . . . . 4 . . . . . . . . . 5 . . . . . . . . . 6 . . . . . . . . . 7 . . . . . . . . . 8 . . . . . . . . . 9

Not at all Somewhat effective Very effective

5) Were the faculty and staff who assisted with the simulation who assisted with these simulations scenarios helpful?

1 . . . . . . . . . 2 . . . . . . . . . 3 . . . . . . . . . 4 . . . . . . . . . 5 . . . . . . . . . 6 . . . . . . . . . 7 . . . . . . . . . 8 . . . . . . . . . 9

Not at all Somewhat helpful Very helpful

6) Any additional comments?

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