Shtull-Leber Eytan, Vempati Amrita, Comp Geoff, Narang Aneesh T
University of Arizona College of Medicine, Banner University Medical Center, Department of Emergency Medicine, Phoenix, AZ.
Creighton University School of Medicine Phoenix Program, Maricopa Medical Center, Department of Emergency Medicine, Phoenix, AZ.
J Educ Teach Emerg Med. 2022 Jan 15;7(1):S21-S50. doi: 10.21980/J8W93W. eCollection 2022 Jan.
This case is targeted to emergency medicine residents of all levels.
Upper gastrointestinal bleeding (UGIB) is a common chief complaint encountered in the emergency department, resulting in over 500,000 hospitalizations and 20,000 deaths annually in the United States.1 The diagnosis and management of UGIB in stable patients is typically fairly straightforward. However, there are a number of circumstances where the treatment of UGIB is much more challenging, and emergency medicine (EM) physicians should be familiar with, and have experience managing, these difficult presentations. Massive UGIB can necessitate the need for management of a difficult airway in the setting of airway contamination, as well as placement of a gastroesophageal balloon tamponade device. The appropriate use and indications for performing this high-risk/low-frequency procedure requires dedicated practice. Furthermore, the management of gastrointestinal hemorrhage in a patient with a religious objection to the administration of blood products, including Jehovah's Witnesses, can be especially challenging and requires knowledge of alternative therapies to support blood pressure, oxygen carrying capacity, and decrease coagulopathy.2,3.
By the end of this simulation, learners will be able to: 1) manage a hypotensive patient with syncope and hematemesis, 2) pharmacologically manage an acute UGIB addressing the various causes, 3) recognize worsening clinical status and intervene by performing difficult airway management, 4) place a gastroesophageal balloon tamponade device.
This simulation was conducted with a high-fidelity mannequin with a separate medium-fidelity intubating mannequin that was modified to allow rapid filling of the oropharynx with simulated blood. Due to the COVID-19 pandemic, a total of six EM residents in various levels of training participated in the simulated patient encounter while the rest of the learners watched the simulation and participated in the debrief via video conference.
Following the simulation and debrief session, all the residents, including those who participated in-person and via video conference, were sent a survey via surveymonkey.com to assess the educational quality of the simulation.
Overall residents expressed positive feedback on the scenario, noting that the case was realistic, appropriately complex, and improved their medical knowledge and procedural skills.
This case has a mixture of high-fidelity and medium-fidelity components which can be easily reproduced. The case was extremely useful in teaching EM residents of all levels not only how to manage large volume UGIB in a patient who is also a Jehovah's Witness, but also how to manage the airway and place a gastroesophageal balloon tamponade device. The case starts with a patient presenting with syncope and as the case unfolds, the patient's clinical status deteriorates, requiring learners to resuscitate, intubate, and obtain a gastroesophageal balloon tamponade.Residents commented that managing this case of an UGIB was extremely challenging because it exposed and filled important gaps in both their knowledge and procedural skills. Residents struggled most with identifying alternative therapies to blood products in patients with religious objections, and the step-by-step process of placing a Blakemore tube.
Upper gastrointestinal bleed, hemorrhagic shock, Jehovah's Witness, difficult airway.
本病例面向各级急诊医学住院医师。
上消化道出血（UGIB）是急诊科常见的主要就诊原因，在美国每年导致超过50万例住院和2万例死亡。1稳定患者的UGIB诊断和管理通常相当简单。然而，在许多情况下，UGIB的治疗更具挑战性，急诊医学（EM）医生应熟悉并具备处理这些复杂病情的经验。大量UGIB可能需要在气道污染的情况下处理困难气道，以及放置胃食管气囊压迫装置。进行这种高风险/低频操作的适当使用和适应症需要专门的练习。此外，对于包括耶和华见证人在内的对输血制品有宗教异议的患者，胃肠道出血的管理可能特别具有挑战性，需要了解替代疗法以支持血压、氧携带能力并减少凝血病。2,3
在本模拟结束时，学习者将能够：1）管理伴有晕厥和呕血的低血压患者；2）通过药物治疗急性UGIB并应对各种病因；3）识别临床状况恶化并通过进行困难气道管理进行干预；4）放置胃食管气囊压迫装置。
本模拟使用了高仿真人体模型以及一个单独的中等仿真度插管人体模型，该模型经过改造以允许用模拟血液快速填充口咽。由于新冠疫情，共有六名处于不同培训阶段的EM住院医师参与了模拟患者会诊，其余学习者观看模拟并通过视频会议参与汇报。
在模拟和汇报环节之后，通过surveymonkey.com向所有住院医师，包括亲自参与和通过视频会议参与的人员发送了一份调查问卷，以评估模拟的教育质量。
总体而言，住院医师对该病例给予了积极反馈，指出该病例真实、复杂度适中，提高了他们的医学知识和操作技能。
本病例结合了高仿真度和中等仿真度的组件，易于重现。该病例对于教授各级EM住院医师不仅如何管理同时也是耶和华见证人的大量UGIB患者，还包括如何管理气道和放置胃食管气囊压迫装置非常有用。病例开始时患者表现为晕厥，随着病例进展，患者的临床状况恶化，要求学习者进行复苏、插管并放置胃食管气囊压迫装置。住院医师评论说，处理这个UGIB病例极具挑战性，因为它暴露并填补了他们知识和操作技能方面的重要空白。住院医师在为有宗教异议的患者识别替代输血制品的疗法以及放置Blakemore管的逐步过程中最为吃力。
上消化道出血、失血性休克、耶和华见证人、困难气道。
