Charnigo Aubri, Yee Jennifer
The Ohio State University, Department of Emergency Medicine, Columbus OH.
J Educ Teach Emerg Med. 2020 Apr 15;5(2):S78-S103. doi: 10.21980/J8C35X. eCollection 2020 Apr.
This simulation was developed to educate emergency medicine residents on the diagnosis and management of high-altitude pulmonary edema (HAPE). This case is also appropriate for senior medical students and advanced practice providers. The principles of crisis resource management, teamwork, and communication are incorporated into the case.
High altitude pulmonary edema may present similarly to pneumonia with nonspecific symptoms, including decreased exercise tolerance, cough, dyspnea with exertion, and fever. Symptoms more specific to HAPE include dyspnea at rest, tachypnea, history of rapid ascent to high altitude, a lowlander patient exposed to high-altitude, or a highlander patient on re-entrance to high altitude after lowland stay. Laboratory and imaging workup may include infiltrates on chest x-ray and leukocytosis.1,2 Of the various forms of altitude sickness, HAPE has the highest fatality rate, estimated at 50% in travellers to the Himalayas who are unable to descend.1 Providers should inquire as to the current elevation of their facility, the patient's recent altitude gain, and the rate of ascent. Treatment priorities include oxygen and immediate descent, as well as supplemental treatment with nifedipine and phosphodiesterase (PDE) inhibitors such as sildenafil or tadalafil.
At the conclusion of the simulation session, learners will be able to:obtain a thorough history relevant to altitude illnessesdevelop a differential for dyspnea in a patient with environmental exposuresdiscuss prophylaxis and management of HAPEdiscuss appropriate disposition of the patient including descent and subsequent appropriate level of care.
This session was conducted using high-fidelity simulation followed by a debriefing session and lecture on the diagnosis and management of HAPE. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This technique includes an observation statement, a statement describing the framework of the observer, and an invitation to review further to explore the participants' frames. An example of this advocacy-inquiry is as follows: "I heard Sam suggest to the team that acetazolamide be given, but then I didn't hear any follow-up discussion. Acetazolamide is often utilized for acute mountain illness prophylaxis or treatment. I wasn't sure if the team did not hear his suggestion or disagreed with the treatment plan. Tell me more." This scenario was designed as a simulation, but it could be adapted as an oral boards case.
Our residents were provided with a survey at the completion of the simulation and debriefing to rate different aspects of the simulation, as well as to provide qualitative feedback.
Participants expressed positive feedback, with comments focused on appreciating the review of the presentation, diagnosis, and treatment of altitude illness. The emergency medicine residents surveyed currently practice in a low altitude setting and were appreciative to simulate a scenario to which they might otherwise not get exposure during their residency. Our simulation center's feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form. This session received all 6 or 7 scores (consistently effective/very good or extremely effective/outstanding) other than a 5 for setting the stage, a 4 for maintaining an engaging context for learning, and two 5s for structured debriefing.
This was an effective method to review high altitude illness with learners that may otherwise get limited exposure to such clinical cases during residency. Learners had a broad range of differential diagnoses and demonstrated variable levels of knowledge related to the diagnosis and treatment of high-altitude illness. We used visual stimuli and a reminder from our nurse to reinforce for the learners that the case was taking place at a critical access emergency room at 11,000 feet of elevation.
Medical simulation, high altitude pulmonary edema, high altitude cerebral edema, altitude sickness, emergency medicine, wilderness medicine.
本模拟旨在对急诊医学住院医师进行高原肺水肿（HAPE）诊断与管理方面的培训。该病例也适用于高年级医学生和高级执业医疗人员。病例中融入了危机资源管理、团队协作及沟通的原则。
高原肺水肿的症状可能与肺炎相似，表现为非特异性症状，包括运动耐力下降、咳嗽、劳力性呼吸困难和发热。HAPE更具特异性的症状包括静息时呼吸困难、呼吸急促、快速攀登至高原的病史、暴露于高原环境的平原居民患者，或在低海拔停留后再次进入高原的高原居民患者。实验室及影像学检查可能包括胸部X光片上的浸润影和白细胞增多。1,2在各种高原病中，HAPE的死亡率最高，据估计，无法下山的前往喜马拉雅山的旅行者中死亡率为50%。1医疗人员应询问其所在机构的当前海拔、患者近期的海拔上升情况以及上升速度。治疗重点包括吸氧和立即下山，以及使用硝苯地平和磷酸二酯酶（PDE）抑制剂（如西地那非或他达拉非）进行辅助治疗。
在模拟课程结束时，学习者应能够：获取与高原病相关的详尽病史；针对有环境暴露史的呼吸困难患者制定鉴别诊断；讨论HAPE的预防和管理；讨论患者的适当处置，包括下山及后续适当的护理级别。
本课程采用高保真模拟，随后进行总结汇报环节以及关于HAPE诊断与管理的讲座。总结汇报方法可由参与者自行决定，但作者采用了支持性询问技巧。该技巧包括观察陈述、描述观察者框架的陈述，以及邀请进一步探讨以了解参与者的框架。这种支持性询问的一个示例如下：“我听到山姆向团队建议给予乙酰唑胺，但之后我没有听到任何后续讨论。乙酰唑胺常用于急性高原病的预防或治疗。我不确定团队是没有听到他的建议还是不同意治疗方案。请详细说说。”此场景设计为模拟，但也可改编为口试病例。
在模拟和总结汇报结束后，我们为住院医师提供了一份调查问卷，以对模拟的不同方面进行评分，并提供定性反馈。
参与者给出了积极反馈，评论主要集中在对高原病的表现、诊断和治疗回顾的赞赏。接受调查的急诊医学住院医师目前在低海拔地区工作，他们很感激能模拟这样一个在住院期间可能无法接触到的场景。我们模拟中心的反馈表基于医疗模拟中心的医疗保健模拟总结汇报评估（DASH）学生版简表。除了在设定场景方面得分为5分、在保持引人入胜的学习情境方面得分为4分以及在结构化总结汇报方面有两个5分之外，本课程在其他所有方面都获得了6分或7分（始终有效/非常好或极其有效/出色）。
这是一种与学习者复习高原病的有效方法，否则他们在住院期间接触此类临床病例的机会可能有限。学习者有广泛的鉴别诊断范围，并且在高原病诊断和治疗方面表现出不同程度的知识水平。我们使用了视觉刺激，并通过护士的提醒，向学习者强化该病例发生在海拔11000英尺的关键急救急诊室。
医学模拟、高原肺水肿、高原脑水肿、高原病、急诊医学、野外医学。
