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A 49 year-old female patient was brought to the Emergency Room (ER) by Ambulance with severe aeidosis (pH < 6.9) and evolving multi-system-organ-failure (MSOF). Decreasing level of consciousness and hypoxie respiratory failure neeessitated endotracheal intubation. Severe hypotension and atrial fibrillation necessitated vasopressors and eardioversion. She had severe anion-gap metabolic acidosis, and a lactate measured by a point-of-care (POC) arterial-blood-gas (ABC) analyzer of 42 mmol/L. Limited history was available. The Intensive Care Unit (ICU) team assumed care, and notified Surgery in case this lactate elevation represented severe mesenteric ischemia thus required urgent exploratory laparotomy. Sedation preeluded an adequate abdominal examination. Abdominal X-ray showed no abnormal bowel, thumbprinting, or portal venous gas. Although eonsent was obtained for immediate laparotomy, we delayed to permit aggressive resuseitation, obtain an abdominal CT, and optimize hemodynamies and acid-base. The patient was admitted to the ICU. Admission laboratory work included plasma lactate. This sample was drawn minutes after the ABC sample. Unexpectedly, the plasma lactate was only 1.5mmol/L (compared to 42 mmol/L). Two hours later, laboratory investigations showed an increased serum osmolarity (353 mOsm/L), and an osmolar gap (33). Urine analysis revealed calcium oxalate and hippurate crystals. Therefore, a stat ethylene glyeol (EG) level was ordered and found to be 15 mmol/L. As such, it was now clear that the diagnosis was one of EG poisoning. Resuscitation continued, but now included high-flux dialysis and ethanol-infusion to counter EG. Both POC and laboratory samples were repeated and confirmed the high POC lactate and comparatively low plasma-lactate, showing that the discrepancy was real. The EG level decreased rapidly with a decrease in the POC lactate. Plasma lactate measured from laboratory testing never exceeded 3.6 mmol/L. The abdominal CT was grossly normal and no surgery was performed. The patient progressed well and was discharged from ICU within two weeks. She admitted to deliberate EG ingestion, and agreed to this report on condition of anonymity. This case demonstrates how misdiagnosis, including inappropriate laparotomy and delays in EG therapy, could occur. However, we were eager to determine why discrepant lactates values occurred, and whether this 'lac-gap' might be useful both for diagnosis and therapy. As such, it was time to move from the resuscitation bay to the laboratory. [ABSTRACT FROM AUTHOR]

Background: This manuscript is part-three of a three-part series on Medical Simulation. Part-one addressed the 'why' of Simulation, namely, why Medical Simulation offers novel opportunities to improve education, continuing-competency, and patient safety. Part-two focused on the 'how' of simulation, namely, how to design, implement, and maintain a viable pro-gram. Part-three will now cover the 'what', namely what the future directions are likely to be, what sort of programs are currently available, and what evidence supports their implementation.Definitions: Our definition of 'Medical Simulation' means any technique, 'low-tech' or 'high tech', that attempts to realistically recreate clinical situations and allow training with minimum patient risk. In this way it resembles the 'war-games' of the military or 'flight simulators' of aviation. Medical training has always involved graduated acceptance of decision-making and supervised practice. Equally, examinations have long included actors. As such, medical training has always incorporated a degree of simulation of real practice. What has changed is the explosion of avail-able technology; the principles of adult education, the focus on patient safety, and the expectation of proof via research. Simulation is therefore a huge topic. We hope to offer a concise introduction. [ABSTRACT FROM AUTHOR]

Background: This manuscript is part-two of a three-part series on Medical Simulation. Part-one addressed the 'why' of Simulation, namely, why Medical Simulation offers novel opportunities to improve education, continuing-competency, and patient safety. Part-two focuses on the 'how' of simulation, namely, how to design, implement, and maintain a viable pro-gram. Part-three will cover the 'what', namely what the future directions are likely to be, what sort of pro-grams are currently available, and what evidence sup-ports their implementation.Definitions: Our definition of 'Medical Simulation' means any technique, 'low-tech' or 'high tech', that attempts to realistically recreate clinical situations and allow training with minimum patient risk. In this way it resembles the 'war-games' of the military or 'flight simulators' of aviation. Medical training has always involved graduated acceptance of decision-making and supervised practice. Equally, examinations have long included actors. As such, medical training has always incorporated a degree of simulation of real practice. What has changed is the explosion of avail-able technology; the principles of adult education, the focus on patient safety, and the expectation of proof via research. Simulation is therefore a huge topic. We hope to offer a concise introduction. [ABSTRACT FROM AUTHOR]