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Abstract Background Many World Trade Center disaster (WTC) rescue and recovery workers (WTC RRWV) were exposed to toxic inhalable particles. The impact of WTC exposures on lung cancer risk is unclear. Methods Data from the WTC Health Program General Responders Cohort (WTCGRC) were linked to health information from a large New York City health system to identify incident lung cancer cases. Incidence rates for lung cancer were then calculated. As a comparison group, we created a microsimulation model that generated expected lung cancer incidence rates for a WTC‐ and occupationally‐unexposed cohort with similar characteristics. We also fitted a Poisson regression model to determine specific lung cancer risk factors for WTC RRWV. Results The incidence of lung cancer for WTC RRWV was 39.5 (95% confidence interval [CI]: 30.7–49.9) per 100,000 person‐years. When compared to the simulated unexposed cohort, no significant elevation in incidence was found among WTC RRWV (incidence rate ratio [IRR] 1.34; 95% CI: 0.92–1.96). Predictors of lung cancer incidence included age, smoking intensity, and years since quitting for former smokers. In adjusted models evaluating airway obstruction and individual pre‐WTC occupational exposures, only mineral dust work was associated with lung cancer risk (IRR: 2.03; 95% CI: 1.07–3.86). Discussion In a sample from a large, prospective cohort of WTC RRWV we found a lung cancer incidence rate that was similar to that expected of a WTC‐ and occupationally‐unexposed cohort with similar individual risk profiles. Guideline‐concordant lung cancer surveillance and periodic evaluations of population‐level lung cancer risk should continue in this group.

Abstract Healthcare organizations strive to deliver safe, high-quality, efficient care. These complex systems frequently harbor gaps, which if unmitigated, could result in harm. Systems-focused simulation (SFS) projects, which include systems-focused debriefing (SFD), if well designed and executed, can proactively and comprehensively identify gaps and test and improve systems, enabling institutions to improve safety and quality before patients and staff are placed at risk. The previously published systems-focused debriefing framework, Promoting Excellence and Reflective Learning in Simulation (PEARLS) for Systems Integration (PSI), describes a systematic approach to SFD. It includes an essential “pre-work” phase, encompassing evidence-informed steps that lead up to a SFD. Despite inclusion in the PSI framework, a detailed description of the pre-work phase, and how each component facilitates change management, was limited. The goal of this paper is to elucidate the PSI “Pre-work” phase, everything leading up to the systems-focused simulation and debriefing. It describes how the integration of project and change management principles ensures that a comprehensive collection of safety and quality issues are reliably identified and captured.

Abstract Healthcare systems are urged to build facilities that support safe and efficient delivery of care. Literature demonstrates that the built environment impacts patient safety. Design decisions made early in the planning process may introduce flaws into the system, known as latent safety threats (LSTs). Simulation-based clinical systems testing (SbCST) has successfully been incorporated in the post-construction evaluation process in order to identify LSTs prior to patient exposure and promote preparedness, easing the transition into newly built facilities. As the application of simulation in healthcare extends into the realm of process and systems testing, there is a need for a standardized approach by which to conduct SbCST in order to effectively evaluate newly built healthcare facilities. This paper describes a systemic approach by which to conduct SbCST and provides documentation and evaluation tools in order to develop, implement, and evaluate a newly built environment to identify LSTs and system inefficiencies prior to patient exposure.

Introduction The American Academy of Pediatrics recommends vitamin K prophylaxis at birth for all newborns to prevent vitamin K deficiency bleeding (VKDB). Despite a lack of evidence for serious harms, barriers to prophylaxis, including parental refusal, are rising, as are cases of VKDB. Methods This simulation involved an infant presenting to the emergency department who decompensated due to a cerebral hemorrhage caused by VKDB and was treated by pediatric and emergency providers. The case was incorporated into the fellow and division monthly curricula, and participants completed postsimulation surveys. The patient required a secure airway, seizure management, vitamin K, and a fresh frozen plasma infusion upon suspicion of the diagnosis, plus a coordinated transfer to definitive care. The case included a description of the simulated case, learning objectives, instructor notes, an example of the ideal flow of the scenario, anticipated management mistakes, and educational materials. Results The simulations were carried out with 48 total participants, including 40 fellows and eight attendings, from five different training institutions over 1 year. In surveys, respondents gave overall positive feedback. Ninety-four percent of participants gave the highest score on a Likert scale indicating that the simulation was relevant, and over 80% gave the highest score indicating that the experience helped them with medical management. Discussion This simulation trained physicians how to recognize and treat a distressed infant with VKDB. The case was perceived to be an effective learning tool for both fellow and attending physicians.

BackgroundVeterans are at increased risk of lung cancer and many have comorbidities such as chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). We used simulation modeling to assess projected outcomes associated with different management strategies of Veterans with stage I non-small cell lung cancer (NSCLC) with COPD and/or CAD.Patients and methodsUsing data from a cohort of 14,029 Veterans (years 2000-2015) with NSCLC we extended a well-validated mathematical model of lung cancer to represent the management and outcomes of Veterans with stage I NSCLC with COPD, with or without comorbid CAD. We simulated multiple randomized trials to compare treatment with lobectomy, limited resection, or stereotactic body radiation therapy (SBRT). Model output estimated expected quality adjusted life years (QALY) of Veterans with stage I NSCLC according to age, tumor size, histologic subtype, COPD severity and CAD diagnosis.ResultsFor Veterans ConclusionsThe harm/benefit ratio of treatments for stage I NSCLC among Veterans may vary according to COPD severity and the presence of CAD. This information can be used to direct future research study design for Veterans with stage I lung cancer and COPD and/or CAD.

Introduction Bupropion is a commonly used antidepressant, and overdose can lead to both neurologic and cardiovascular toxicity, including agitation, seizure, tachycardia, QT and QRS prolongation, and rhythm disturbances. Methods We developed this simulation case for attendings, fellows, nurse practitioners, and nurses in the pediatric emergency department (ED). The scenario involved a 13-year-old male presenting to the ED with altered mental status and a generalized tonic-clonic seizure shortly after arrival. The team needed to quickly perform primary and secondary surveys, manage his airway and breathing, and initiate treatment for seizure. The team had to obtain an abbreviated history and include ingestion in the differential. The patient then developed pulseless ventricular tachycardia, and the team needed to respond with high-quality CPR, defibrillation, and advanced airway management. Preparatory materials, a debriefing guide, and scenario evaluation forms assisted with facilitation. Results Twenty-eight physicians, 56 nurses, 10 nurse practitioners, four pharmacists, two students, and one respiratory therapist completed this simulation in 13 sessions. On a 5-point Likert scale, participants agreed with the stated objective of ability to manage a patient with a bupropion overdose (M = 4.09; range, 2-5). The scenario was rated as highly relevant (M = 4.93) and the debriefing as very effective (M = 4.85). Discussion This scenario is a complete educational resource for setting up, implementing, and debriefing in an interprofessional setting. It was well received by learners from diverse professional backgrounds working together in actual care teams in the pediatric ED.

Introduction Altered mental status can be a challenging presenting symptom in children due to the wide differential diagnosis, which ranges from the relatively benign to the life threatening. Marijuana ingestion and unintentional intoxication are becoming an increasingly common cause of altered mental status in children as marijuana use and availability of enticing marijuana edibles increase in the United States. Because children present with altered mental status rather than the typical marijuana toxidrome, appropriately managing these patients in emergency settings can be particularly challenging. Methods This simulation-based curriculum involved the evaluation and management of a 6-year-old boy who presented with altered mental status from acute marijuana intoxication unbeknownst to his parents. Participants systematically evaluated a pediatric patient with a broad differential diagnosis of altered mental status and managed the patient with acute marijuana intoxication. This scenario may be modified based on trainee level (medical student vs. resident vs. fellow). Results A total of 20 trainees comprising six emergency medicine fellows and 14 pediatric residents and medical students participated in this simulation curriculum over three iterations. Trainees consistently rated it as an overall positive learning experience for pediatric altered mental status and toxidrome education. Discussion Low-frequency, high-risk illnesses such as altered mental status due to marijuana intoxication require providers to be familiar with their evaluation and management. This curriculum provides instructors with the materials to successfully implement and improve the simulation over time.

Introduction Although pediatric emergencies commonly occur in the outpatient setting, studies show that primary care providers often rely on hospitals or the emergency medical system to evaluate the distressed patient. This simulation-based curriculum addresses pediatric emergencies encountered by primary care providers. The cases were facilitated by faculty at an annual conference on urgent pediatric problems. Methods Three cases are included in this curriculum: asthma, anaphylaxis, and seizure. Each features a brief narrative description of the case, learning objectives, instructor notes, an example of the ideal flow of the scenario, and anticipated management mistakes. Also provided are tools on optimizing the simulation environment, teamwork and communication, and the debrief. Educational materials are included in the respective medical pathologies. The simulations can be run using a high- or low-fidelity mannequin. Results The simulations were carried out annually for 4 years with over 100 providers. Participants overall felt the curriculum was relevant to their practice in the realms of medical management and patient-provider communication. Discussion These simulation cases train primary care providers to recognize a decompensating patient, activate the emergency response system, and initiate appropriate treatment for acutely ill pediatric patients with asthma, anaphylaxis, or seizure. The cases also reinforce teamwork and communication skills with the intention of improving overall readiness in the office. The simulations have been found to be effective learning tools at the University of Washington, which continues to train outpatient providers in emergency response annually using this curriculum.

Introduction Cardiac tamponade is an uncommon presentation to the pediatric emergency department and requires early recognition and emergent intervention. Methods We developed this patient simulation case to simulate a low-frequency, high-acuity scenario for pediatric emergency medicine fellows and resident physicians in emergency medicine, pediatrics, and family medicine. We ran the case in a pediatric emergency department using a high-fidelity pediatric mannequin and equipment found in the clinical environment, including a bedside ultrasound machine. The case involved a 10-year-old patient with Hodgkin lymphoma who presented with fever, neutropenia, and shock and was found to have a pericardial effusion with tamponade after evaluation. The providers were expected to identify signs and symptoms of shock, as well as cardiac tamponade, and demonstrate appropriate emergent evaluation and management. Required personnel included a simulation technician, instructors, and a nurse. Debriefing tools tailored specifically for this scenario were created to facilitate a formal debriefing and formative learner assessment at the end of the simulation. Results This case has been implemented with 10 pediatric emergency medicine fellows during two 3-year cycles of fellow education. Session feedback reflected a high level of satisfaction with the case and an increased awareness of bedside ultrasound in the identification of cardiac tamponade. Discussion This resource for teaching the critical components for diagnosing and managing unstable cardiac tamponade in the pediatric patient, including use of bedside ultrasound, was well received by pediatric emergency medicine fellows.

Introduction Liquid nicotine exposure is becoming more common in the pediatric population. Toxicity may occur with exposure to small quantities given the high concentrations in solutions available commercially. Effects can include altered mental status, seizure, and death. Methods This simulation-based case involves the identification and management of a toddler presenting with acute liquid nicotine exposure, with emphasis on the general approach to the acutely ill pediatric patient, consideration in toxic exposures, and the presentation of nicotine exposure. Providers should assess airway, breathing, and circulation while concurrently providing supportive care for an actively seizing simulated patient, necessitating appropriate selection of medications and acute airway management. Additionally, providers must maintain a broad differential diagnosis and obtain a focused history to narrow that differential and identify toxic exposure as a cause of the patient's presentation. Preparatory and didactic material is provided to help the instructor prepare the simulation environment, guide learners through the case, and debrief with learners afterward. Results We implemented this curriculum with four pediatric emergency medicine fellows and 15 pediatric residents during two sessions. Feedback was overwhelmingly positive; participants who completed evaluations reported high levels of confidence with knowledge and skills directly related to the educational objectives after participation (mean Likert scores of 4.9 out of 5 in response to effectiveness of the case in teaching evaluation and management of nicotine toxicity). Discussion This comprehensive resource will aid in offering continuing education for providers and specifically in educating learners with regard to acute liquid nicotine exposure in a child.

Introduction Electrical injuries are rare but potentially life-threatening medical emergencies that require providers to manage a critically ill patient while recognizing and treating the unique sequelae associated with the diagnosis. This simulation case is designed to give pediatric and emergency medicine residents, fellows, attendings, and nurses the opportunity to practice these skills in a realistic setting. Methods This simulation-based curriculum was designed for a high-fidelity mannequin in an emergency department resuscitation room but can be adapted to fit a variety of learning environments. The case featured a 16-year-old boy presenting to the emergency department after arresting in the field after sustaining an electrical injury. He developed ventricular tachycardia during the simulation and had significant hyperkalemia, requiring emergent management. The included debriefing tools assisted instructors in providing formative feedback to learners. Results A total of 40 residents, medical students, and fellows participated in this scenario and provided overwhelmingly positive feedback about the learning experience. Mean Likert scores for participant confidence related to learning objectives after the simulation were 4 or greater on a 5-point scale. Discussion This case was developed to help learners at various levels of training recognize and manage a low-frequency, high-acuity scenario in a standardized environment. Participants specifically had the opportunity to perform airway management, cardiopulmonary resuscitation, defibrillation, and management of hyperkalemia, which may present in real life from a multitude of etiologies. The included materials helped prepare and assist facilitators with debriefing, supplemental education, and bidirectional feedback.

Introduction Submersion injury or drowning is a leading preventable cause of pediatric mortality and morbidity. Submersion injuries are often accompanied by hypothermia and asphyxia that can lead to inadequate oxygen delivery to tissues and subsequent cardiac arrhythmias. Methods This simulation-based curriculum involves the identification and management of a submersion injury in a 4-year-old boy who was rescued from a cold-water submersion. The simulated patient is apneic, pulseless, bradycardic, and hypothermic; he is being bag-mask ventilated on arrival without intravenous access. He ultimately develops ventricular fibrillation. Providers must recognize the degree of submersion injury, initiate early airway protection, adequately address circulation, and be alert to developing hypothermia and cardiac arrhythmias to prevent further decompensation. This scenario can be modified based on trainee level (pediatric residents vs. pediatric emergency medicine fellows). Results A total of 22 trainees (PGY 1-PGY 6 pediatric residents and pediatric emergency medicine fellows) participated in this simulation curriculum on separate occasions and rated it as an overall positive learning experience. The curriculum's goal is to provide learners with an opportunity to manage life-threatening pediatric submersion injuries, where the correct steps need to be taken in a limited period of time. Discussion We have provided preparatory materials to help instructors set up, run, and debrief the scenario in a standardized fashion. The debriefing tools allow for adaptation depending on learners' needs and individual experiences during the simulated scenario. Also included are supporting educational materials and a learner feedback form that can be used to evaluate the session.

Introduction Child abuse, also known as nonaccidental trauma (NAT), is an important cause of pediatric morbidity and mortality. The presentation of NAT is often confounded by unclear histories and victims who are unable to provide information. Medical students and trainees may fail to consider NAT as a diagnosis or be unfamiliar with the evaluation process. Methods This curriculum uses simulation, small-group discussion, and didactics to help medical students gain an understanding of presentation of NAT. Using the case of a 2-month-old boy presenting with altered mental status and seizure, participants practice the assessment and management of an acutely ill patient. Small-group discussions facilitate schema building to enhance each participant's ability to recognize and diagnose different diseases that may present as infant seizure and to identify the signs of NAT. Didactics solidify concepts addressed during the simulation and small-group discussions. Results Medical students participating in this course reported that they felt better prepared for their internships and that working through a case with a large differential diagnosis was helpful for their understanding of causes of infant seizures, including abusive head trauma. Discussion This curriculum is unique in that it uses one unifying case to allow participants to demonstrate an understanding of the evaluation and stabilization of a critically ill pediatric patient, develop a broad differential diagnosis for a nonspecific symptom, and prioritize and evaluate possible etiologies through the gathering and interpretation of data. This curriculum may be used independently or in conjunction with other learning activities as part of a pediatric boot camp.

Abstract Introduction Seizures are a common complaint in the pediatric emergency department. Effective care of this potentially life-threatening medical emergency requires the ability to stabilize the patient while simultaneously identifying and treating the underlying cause. This simulation-based curriculum involves the identification and management of a generalized seizure in a 4-month-old infant secondary to hyponatremia. The target audience is pediatric and emergency medicine residents, fellows, faculty, and nurses. Methods There is no prerequisite preparation for the trainees prior to the case. The simulation scenario, simulation environment preparation, teamwork and communication glossary, and PowerPoint presentation are provided for the instructor in preparation for the simulation case. The setting is the emergency department (ED) resuscitation room. The simulation can be conducted in the ED resuscitation room or in the simulation lab. We used a high-fidelity infant mannequin. The debriefing tools have been tailored specifically for this scenario with advice on how the instructor can edit them for different learners. Results We have used this curriculum with a group of six pediatric emergency medicine fellows at various stages of their training at our institution. The curriculum received overwhelmingly positive feedback through the evaluation form. Discussion This resource will help support standardization of the teaching process, assisting simulation instructors to maximize their impact. In our experience, we have found that instructors who teach intermittently can successfully foster simulation-based education using similar resources. The inclusion of a learner feedback form supports the instructor's ongoing growth while helping faculty to document their teaching efforts.

Abstract Congenital adrenal hyperplasia is a group of autosomal recessive diseases marked by mutation of the genes involved in steroidogenesis. There are many types of the disease with 21-hydroxylase deficiency comprising 90-95% of cases. Medical providers must be able to identify the signs and symptoms of salt-wasting, specifically related to hyperkalemia and hyponatremia. When presented with a critical potassium level, medical providers must rapidly stabilize the cardiac membranes to prevent ventricular arrhythmias. The goal of this scenario is to provide the learner with an opportunity to manage life-threatening pediatric hyperkalemia due to adrenal crisis, where both electrolyte abnormalities and the underlying etiology must be addressed. We include extensive preparatory material to help the instructor prepare the environment and learners. The debriefing tools have been tailored specifically for this scenario, with advice on how the instructor can edit them for different learners. The suggested debriefing comments/questions in the Skill Training section are written in the advocacy-inquiry debriefing style that would best be supported by formative assessment with adequate time for learners to reflect. These are the debriefing questions we use the most in our ongoing educational curriculum. The Medical Management and Teamwork Evaluations/Debriefing Forms are written in the plus/delta debriefing style and are a better fit for summative assessment. We use these less frequently, often as part of our quality improvement work. Because not all the material will be applicable to every instructor and every set of learners, we recommend instructors spend at least 30 minutes of preparatory time with all the materials to ensure familiarity, confidence, and maximal efficacy.

Abstract Rapid identification and stabilization of traumatic brain injury (TBI) and its potential sequelae (hypoxia, hypotension, increased intracranial pressure leading to cerebral herniation and death) is critical to ensure the best long term neurological outcomes. As definitive care (surgical decompression) may only be available at pediatric trauma centers, prompt transfer to an appropriate pediatric trauma facility can be critical. This simulation-based scenario teaches learners to recognize and manage pediatric TBI injury with an integrated team communication focus. Learners will participate in a simulation scenario and be asked to identify the signs and symptoms of traumatic brain injury and its management. At the end of training, the learners should be able to recognize the seriousness of the situation and effectively coordinate a full resuscitation team. This resource includes extensive preparatory material to help instructors prepare the environment and reflect on their learners. Background information on simulation and debriefing theory is also provided. Two different types of debriefing tools have been tailored specifically for this scenario, with advice on how the instructor can modify them further for learners with different levels of experience and different opportunities for improvement. This scenario is one component of a larger course: the Pediatric Emergency Medicine Simulation course. Over the past four years, we have found that learners' performance in medical decision making, technical skills, and teamwork skills improve over time.

Abstract Introduction Thyroid storm, also known as thyrotoxic crisis, is an uncommon but potentially life threatening medical emergency if not immediately recognized and treated aggressively. Its signs and symptoms may mimic that of other etiologies including infection and ingestion. It is imperative that pediatric health care providers are able to recognize potential warning signs and initiate appropriate evaluation and management. Methods This scenario teaches learners to recognize and manage thyroid storm in the emergency setting. It is simulation-based, designed for manikin-based simulation equipment, with an integrated team communication focus. Learners will participate in a simulation scenario and be asked to identify the signs and symptoms of thyroid storm, appropriate evaluation within the emergency department and emergency management. At the end of training, the learners should be able to recognize the seriousness of the situation and manage a full resuscitation team. The primary complications for the team to recognize and manage are altered mental status and vital sign instability. Results The simulation curriculum presented here was implemented at our institution using pediatric emergency medicine fellows as the targeted learners. Because of the high level of training of the learners, we elected to use the optional stage. The fellows provided feedback regarding the session afterwards. Their comments reflected appreciation for a rare presentation that many had not seen clinically before but that shares features with many other potential diagnoses such as infection or toxidrome. They felt it served as a good educational experience and will remind them to keep an open differential diagnosis and seek out key features from the history or exam that may support and endocrinologic etiology for fever, tachycardia and altered mental status. They also reported that altering the simulation mannequin to have a goiter was helpful. Discussion Thyroid storm, also known as is an uncommon but potentially life threatening medical emergency if not immediately recognized and treated aggressively. This resource teaches learners to recognize and manage thyroid storm in the emergency setting.

Abstract Injury in general, is the leading cause of death for children in the United States and most developed countries. Blunt abdominal trauma occurs in 10-15% of injured children, with two typical patterns: isolated injury caused by a direct blow or as a part of a high-mechanism, multisystem trauma. Rapid identification of blunt abdominal trauma and its potential sequelae (e.g., hemorrhagic shock, bowel injury) is critical. Management should include monitoring, supplemental 100% oxygen, recruitment of additional resources, airway protection, and intravascular volume replacement. Rapid sequence intubation should be considered for unstable patients. Definitive care may only be available at trauma centers; thus, prompt transfer to a pediatric trauma facility may be critical. The goal of this scenario is to provide the learner with an opportunity to manage pediatric blunt abdominal trauma with hemorrhagic shock, where the correct steps need to be taken in a limited period of time. We included extensive preparatory material, to help the instructor prepare the environment and learners. The debriefing tools have been tailored specifically for this scenario, with advice on how the instructor can edit them for different learners. Supplemental learner handouts help reinforce teaching points. In addition, handouts reviewed by learners who are not able to attend a specific session generate questions amongst the residents themselves and more interest for future simulation sessions. The inclusion of a learner feedback form promotes continuous improvement of the scenario, environmental preparation, and debriefing. In addition, it helps faculty document their teaching efforts. As part of the larger pediatric emergency medicine curriculum which features recurring educational goals and objectives, we found that learners' performance (in medical management, technical skills, and teamwork) improves over time.

Abstract This scenario teaches learners to recognize and manage a critically ill patient with bronchiolitis in the emergency setting. A subset of patients with bronchiolitis experience severe respiratory symptoms requiring aggressive ventilatory support. Many of these patients have required endotrachial intubation. Recently, more of these patients have been managed with high flow nasal canula (HFNC) oxygen therapy, with retrospective studies showing decreased rates of intubation of bronchiolitic patients when this therapy has been adopted. This curriculum involves a common disease process with potential serious complications. This resource is simulation based, designed for manikin-based simulation equipment, with an integrated team-communication focus. Learners will participate in a simulation scenario and be asked to identify the signs and symptoms of bronchiolitis and their management. Two versions of this scenario are presented. The first version presents respiratory distress secondary to bronchiolitis which meets criteria for the use of high flow nasal canula oxygen therapy or nasal continuous positive airway pressure. The second version of the scenario presents respiratory failure secondary to bronchiolitis which requires intubation. The selection of which version is used should be based on individual learning objectives and availability of different therapies. There are also optional sections of both versions of the scenario requiring the recognition and management of tension pneumothorax. At the end of training, the learners should be able to recognize the seriousness of the situation and manage a full resuscitation team. The primary complications for the team to recognize and manage are respiratory distress and impending respiratory failure. This curriculum involves a common disease process with potential serious complications. It incorporates a novel treatment modality, while providing an alternative scenario for centers where use of high flow nasal cannula (HFNC) is not standard of care. It can be used both for teaching and as a tool to evaluate the implementation of HFNC. It is adaptable to the training level of the learner. Finally it utilizes simulation to promote and teach teamwork and effective communication skills.

Abstract Introduction Anesthesia residents and other professionals are far removed from their experiences in gross anatomy dissection. To address this, efforts were made to create videos that would remind residents of the important gross anatomy underlying the procedures that they were performing. This resource includes a set of four videos for teaching upper extremity peripheral nerve block anatomy and technique to anesthesia residents. Methods One week before the nerve block lecture, residents were assigned the four videos to review in order to get a sense of the procedure. Each video begins with a cadaver dissection of the gross anatomy pertinent to the nerve block being taught, then the physical landmarks are demonstrated on a standardized patient, and finally, ultrasound images and techniques for guiding the injection are displayed. At the beginning of the lecture parts of the videos were reviewed and questions were addressed. More detailed instruction and technique was then given, including medication and instrument specifics. The residents were then given permanent access to the videos. Results When first implemented in 2012, an initial paper survey and quiz was administered to 20 residents. The most preferred feature was the ultrasound demonstration with the patient and cadaver. Before watching the videos a mean previous knowledge score among all residents was 5/10 with a SD of 1.8. After watching the videos the mean knowledge assessment score was 8.2/10 with a SD of 1.2. In early 2014 a survey was administered to 22 second-year medical students to assess the videos as a tool for clinical correlation. Qualitative feedback, while overall positive in nature, suggested greater power over varying speeds, more illustration, and cosmetic changes. The survey also showed an increase in the mean knowledge assessment score from 65% to 87.9% before and after viewing the videos. Discussion While there are videos on performing peripheral nerve blocks, these videos include gross anatomy. Having gross anatomy, surface landmarks, and ultrasound in the same instruction helps to make important connections and we have yet to find a set of videos available that meets this same objective. In addition, this format allows students to progress at their own pace and convenience, while minimizing needless repetition from instructors.

Abstract Pediatric seizures impact children worldwide. In developed countries, the prevalence of epilepsy is 4-8 per 1,000 children. Of all children, up to 5% will have a febrile seizure before reaching age 5. Pediatric seizures can consist of a number of different seizure types. For this scenario, the focus is on generalized pediatric seizures, which involve both hemispheres of the brain and result in impaired mental status and bilateral motor manifestations (tonic and clonic movements). Medical providers must recognize a generalized seizure early, when a pediatric patient is more likely to respond favorably to treatment. Medical providers must anticipate and treat the primary complication of respiratory insufficiency to prevent additional morbidity or mortality. The goal of this scenario is to provide the learner with an opportunity to manage a potentially life-threatening pediatric seizure, where the correct steps need to be taken in a limited period of time. This resource provides a comprehensive package to support instructors teaching pediatric seizure using a simulation-based modality. It includes background knowledge, presimulation preparation guidelines, a simulation scenario, tools to help evaluate team performance and guide debriefing, tools to elicit student feedback on the instructor's performance, and supplemental educational materials for instructors to provide to their students. We included extensive preparatory material, to help the instructor prepare the environment and learners. The debriefing tools have been tailored specifically for this scenario, with advice on how the instructor can modify them for learners with different levels of experience and opportunities for improvement. This resource will help support standardization of the teaching process, allowing simulation instructors maximize their impact. Over the past four years, we found that instructors are better able to anticipate and optimize discussion of debriefing points when utilizing this resource.

Abstract Supraventricular tachycardia (SVT) is the most common rhythm disturbance in children, affecting approximately 1 in 250 children. Its incidence is greater in critically ill children or those with congenital or acquired heart disease. Medical providers should recognize children in SVT early. Medical providers should initiate reinstitution of a normal sinus rhythm rapidly and beware of the risk for potential deterioration of the rhythm if not treated appropriately in a timely manner. The goal of this scenario is to provide the learner with an opportunity to manage life-threatening pediatric supraventricular tachycardia, where the correct steps need to be taken in a limited period of time. We included extensive preparatory material, to help the instructor prepare the environment and learners. The debriefing tools have been tailored specifically for this scenario, with advice on how the instructor can edit them for different learners. This resource will help support standardization of the teaching process, helping simulation instructors maximize their impact. Supplemental learner handouts can reinforce teaching points. The inclusion of a learner feedback form supports the instructor's ongoing growth while helping faculty to document their teaching efforts. In addition, we created this resource to stand alone, and providing a standard collection of instructor resources since we have had to rely on a variety of instructors to implement our curriculum. Over the past 4 years, we found that instructors who teach intermittently can successfully foster simulation-based education using this resource. While resources do not replace experience and grounding in simulation education theory, they can help instructors at all levels provide more consistent learning experiences for students.

Abstract Status asthmaticus continues to be a major cause of morbidity and mortality worldwide. Status asthmaticus is characterized by airway inflammation, excessive airway mucous production and/or plugging and bronchospasm, and leading to airflow obstruction. This can result in a progression from respiratory insufficiency to respiratory failure. Medical providers must recognize children in status asthmaticus early when they are more likely to respond favorably to treatment. The goal of this scenario is to provide the learner with an opportunity to manage life-threatening pediatric status asthmaticus, where the correct steps need to be taken in a limited period of time. This resource provides a comprehensive package to support instructors teaching pediatric status asthmaticus. It includes background knowledge, presimulation preparation guidelines, a simulation scenario, tools to help evaluate team performance and guide debriefing, tools to elicit student feedback on the instructor's performance, and supplemental educational materials for instructors to provide their students. Also included are extensive preparatory materials to help the instructor prepare the environment and learners. Debriefing tools have been tailored specifically for this scenario, with advice on how the instructor can edit them for different learners. This resource will help support standardization of the teaching process, helping simulation instructors maximize their impact. Supplemental learner handouts can help reinforce the teaching points. The inclusion of a learner feedback form supports the instructor's ongoing growth while helping faculty to document their teaching efforts.

Abstract Anaphylaxis is a potentially fatal disorder which can mimic other illnesses initially and rapidly progress if not treated. Anaphylaxis is characterized by acute onset of skin or mucosal changes and respiratory compromise, reduced blood pressure, or end organ dysfunction. Medical providers must recognize children in anaphylaxis early and initiate systemic treatment rapidly to prevent further decompensation and cardiopulmonary failure. The goal of this scenario is to provide the learner with an opportunity to manage life-threatening pediatric anaphylaxis, where the correct steps need to be taken in a limited period of time. Included are extensive preparatory materials to help the instructor prepare the environment and learners. The debriefing tools have been tailored specifically for this scenario, with advice on how the instructor can edit them for different learners. This resource will help support standardization of the teaching process, allowing simulation instructors to maximize their impact. Supplemental learner handouts can help reinforce the teaching points. The inclusion of a learner feedback form supports the instructor's ongoing growth while helping faculty document their teaching efforts. This scenario, by itself, can be inserted into other ongoing educational programs. It provides a standard collection of instructor resources. This has been particularly helpful, since we have had to rely on a variety of instructors to implement our curriculum. Over the past 4 years, we found that by using this as an individual resource, instructors who teach intermittently can successfully foster simulation-based education. While these resources do not replace experience and grounding in simulation education theory, they can help instructors at all levels provide more consistent learning experiences for students.

Abstract Septic shock continues to be a major cause of morbidity and mortality in children. Early recognition and management of severe sepsis and septic shock in the first hour of resuscitation have been shown to decrease mortality. Medical providers must recognize children in septic shock early precisely because they are more likely to respond favorably to treatment. The goal of this scenario is to provide the learner with an opportunity to manage life-threatening pediatric septic shock, where the correct steps need to be taken in a limited period of time. This resource provides a comprehensive package to support instructors teaching pediatric septic shock. It includes background knowledge, presimulation preparation guidelines, a simulation scenario, tools to help evaluate team performance and guide debriefing, tools to elicit student feedback on the instructor's performance, and supplemental educational materials for instructors to provide their students. Also included are extensive preparatory material, to help the instructor prepare the environment and learners. The debriefing tools, have been tailored specifically for this scenario, with advice on how the instructor can tailor them to different learners. This resource will help support standardization of the teaching process, helping simulation instructors maximize their impact. Supplemental learner handouts can help reinforce the teaching points even after the session has finished. The inclusion of a learner feedback form supports the instructor's ongoing growth while helping faculty to document their teaching efforts.

Abstract This module provides a comprehensive package to support instructors teaching pediatric hypovolemic shock. It includes background knowledge, presimulation preparation guidelines, a simulation scenario, tools to help evaluate team performance and guide debriefing, and tools to elicit student feedback on the instructor's performance. Additionally, it has supplemental educational materials for instructors to provide their students. We included extensive preparatory material to help the instructor prepare the environment and learners. The debriefing tools, to assist the instructor in their teaching, have been tailored specifically for this scenario with the addition of advice on how the instructor can tailor them to different learners. This course will help support standardization of the teaching process, helping simulation instructors maximize their impact. Supplemental learner handouts can help reinforce the teaching points even after the session has finished. The inclusion of a learner feedback form supports the instructor's ongoing growth while helping faculty to document their teaching efforts. This is the most comprehensive collection of educational material available for this topic. This scenario is one component of a larger course: the Pediatric Emergency Medicine Simulation Curriculum. Exposure to multiple scenarios within the curriculum fosters reinforcement of recurring learning objectives (e.g., closed loop communication) over time. A companion curriculum, the Pediatric Toxidrome Simulation Curriculum, is also available on MedEdPORTAL.

Recent research has demonstrated colony-level sublethal effects of imidacloprid on bumble bees, affecting foraging and food consumption, and thus colony growth and reproduction, at lower pesticide concentrations than for honey bee colonies. However, these studies may not reflect the full effects of neonicotinoids on bumble bees because bumble bee life cycles are different from those of honey bees. Unlike honey bees, bumble bees live in colonies for only a few months each year. Assessing the sublethal effects of systemic insecticides only on the colony level is appropriate for honey bees, but for bumble bees, this approach addresses just part of their annual life cycle. Queens are solitary from the time they leave their home colonies in fall until they produce their first workers the following year. Queens forage for pollen and nectar, and are thus exposed to more risk of direct pesticide exposure than honey bee queens. Almost no research has been done on pesticide exposure to and effects on bumble bee queens. Additional research should focus on critical periods in a bumble bee queen’s life which have the greatest nutritional demands, foraging requirements, and potential for exposure to pesticides, particularly the period during and after nest establishment in the spring when the queen must forage for the nutritional needs of her brood and for her own needs while she maintains an elevated body temperature in order to incubate the brood.