Chest Pain on the Ward: A Simulation Scenario for Rural Family and Emergency Medicine Trainees

Chest pain is a frequently encountered emergency room presentation, of which about 15% of cases are due to acute coronary syndromes. Cardiogenic shock is a relatively uncommon complication with associated high morbidity and mortality. Emergency medicine practitioners frequently encounter critically ill patients that require quick, definitive treatment to optimize patient outcomes. These high acuity presentations often are of relatively low occurrence which makes training residents and learners challenging. Simulation-based medical education has been shown to enhance patient outcomes by teaching these high acuity low occurrence (HALO) presentations in a safe environment. Herein we describe a simulation scenario of a patient with cardiogenic shock secondary to acute coronary syndrome. It consists of a step-wise, detailed summary of the case, along with modifiers to adjust the case for repeated use, learning objectives, and a suggested evaluation.


Introduction
Ischemic heart disease (IHD) is the leading cause of death among adults in Canada, with more than 600,000 people dying annually [1]. Coronary artery disease (CAD) accounts for the vast majority of patients with IHD. The main symptom of CAD is chest pain, which results in over 8 million presentations to the emergency department annually [2]. Of those, approximately 15% have acute coronary syndrome (ACS), a third of whom have an acute myocardial infarction (MI) [3]. About 5-10% of patients with acute MI have cardiogenic shock, rendering it a rare but potentially lethal presentation.
Cardiogenic shock is the leading cause of in-hospital death in patients with acute MI [3] and seen in 4-8% of patients with ST-segment elevation myocardial infarction (STEMI) [4]. Depending on the area and extent of infarct, mechanical complications, including rupture of the septum, ventricular wall, or chordae tendinae, may or may not be present [5]. It occurs less frequently in patients with non-ST-segment elevation myocardial infarction (NSTEMI). About 10% of acute MI patients who will develop cardiogenic shock have it at presentation, with the median onset after arrival being approximately six hours. Cardiogenic shock is associated with a mortality of about 40%, with about half of the deaths occurring within the first 48 hours after presentation [6]. Therefore, early recognition of cardiogenic shock or ongoing myocardial ischemia is key for rural family medicine trainees. Early and effective management is key in restoring perfusion and optimizing patient outcomes.
People living in rural communities report higher levels of cardiovascular disease risk factors, including smoking, obesity, and inactivity compared to their urban counterparts. They also report higher levels of heart disease, hypertension, and stroke [7]. Due to a multitude of factors, cardiologists are less likely to establish a full-time practice in rural areas [8]. Consequently, rural patients have fewer overall visits to specialists and tend to rely heavily on care provided locally by primary care physicians. Predicting the clinical course in these critically ill patients can be quite challenging and determining whether a particular rural hospital has the capacity to care for such a patient is complex. Patients often want to remain local for treatment whenever possible, however, transport to a tertiary care centre sometimes becomes necessary [9].
Presently, teaching around this subject is largely didactic. Continuing medical education (CME) courses such as advanced cardiac life support (ACLS) offer a mix of didactic lessons and simulated cases. Simulation-based medical education has been repeatedly shown to affect learner skills, knowledge and attitudes, and patient outcomes [10]. It serves as a medium to teach high acuity low occurrence (HALO) and crisis resource management (CRM) skills and presentations in a safe environment. As such, it has become a mainstay of many postgraduate medical training programs. Recently, with the transition to the Competency by Design initiative for all Canadian postgraduate medical education programs, simulation will likely take a more predominant role in assessment.
This technical report is designed to train rural family and emergency medicine trainees in recognizing cardiogenic shock and quickly initiating the appropriate management steps. The objectives of this simulation scenario are: 1. Develop an approach to a patient with chest pain.
2. Communicate effectively with team members in the care of a complex, critically ill patient.
3. Recognize and manage evolving chest pain and cardiogenic shock. 4. Develop an approach to intubation in a patient with cardiogenic shock. This report will be presented according to the Context-Inputs-Process-Product model [11].

Context
This simulation scenario was designed for the training of rural family or emergency medicine residents. However, any learner, rural or urban, who attends calls as part of a hospitalist rotation, whether undergraduate or postgraduate, may benefit from participation. It was designed to take place in a community hospital with no subspecialty backup in-house.
The scenario is run with the help of a confederate, an individual who, during the course of the scenario, provides assistance with equipment, provides information about the mannequin not available in other ways (e.g. temperature, colour change), and/or to provide additional realism by playing the role of a relative or staff member [12].
Three to four residents participate in the scenario, one as a team leader and the others in additional roles. If the scenario is run with only one resident, the resident is to assume the role of team leader and available confederates (e.g. nurses, respiratory therapists, other physicians, etc.) can be used as the additional team members. Two facilitators, who were familiar with the scenario and its management, were present during the scenario. One ran the scenario, took notes, and provided prompts as needed. The other acted as a nurse confederate assisting with the scenario in order to meet the learning objectives. They performed tasks for the learners as requested and delivered results and prompts to the learners when needed. When fewer residents are available to partake in the simulation, more confederates may be used to assist the learners.

Equipment
The simulation session was conducted in a simulation lab using a Laerdal SimMan 3G® human patient simulator. The lab was outfitted with equipment, medications, and supplies typically available on a crash cart as well as those needed specifically for this case. The equipment and supplies are used only for simulation and teaching but are the same as what would be used in the hospital. The simulation lab is separate from the hospital and all equipment is clearly marked. The equipment provided included the following items: Higher fidelity simulation, defined as the level of realism associated with a particular simulation activity, is typically desirable. It is normally achieved by manipulating the realism of the simulator, the environment, or the scenario itself [13]. Lower fidelity simulators can be substituted for practice and integration into the scenario.

Process
One week prior to the session, a step-wise, detailed scenario template ( Table 1) was generated and reviewed by the scenario facilitators. This allowed for programming of the mannequin as well as preparation of supporting materials for the scenario itself. In addition, this provided some time for the facilitators to review the scenario and complete a dry run of the scenario to identify any potential problem areas.

Pre-Briefing
A pre-briefing was held with all learners prior to the case. Learners were given a brief orientation to the simulation lab and mannequin. Limitations of simulation were reviewed, in particular addressing technical issues with the mannequin and resource availability. The fiction contract was addressed. This concept, also known as the "suspension of disbelief", encourages healthcare trainees and instructors to accept the simulation exercise as being real for the duration of the scenario in order to make it worthwhile [12]. Finally, learners were advised that the case was strictly formative.

Pre-scenario Information
You are a resident working overnight in the emergency department of your community hospital. A nurse from the inpatient ward comes to your office with an EKG from a patient who was admitted earlier in the day and is currently complaining of chest pain.

The Simulation
Table 1 depicts a step-wise, detailed scenario that was submitted to technical staff to run the simulation. Investigations that may be ordered, including EKG ( Figure 1) and a chest radiograph ( Figure 2) are provided upon learner request.

Debriefing and Post-Scenario Didactics
Following the conclusion of the scenario, facilitators and learners participated in a debriefing session. The debriefing was led by an experienced educator. Care was taken to ensure that the number of instructors to learners was approximately 1:1. Multiple debriefing models have been validated and choice usually is dictated by facilitator preference [16]. In this particular scenario, a modified plus/delta model was used [12]. Confederates and any simulated patients attended the start of the debriefing session to provide and receive feedback.
The content of the debriefing session was guided by the case learning objectives, yet it was a fluid process to accommodate the evolving dynamics of the team behaviour. That is, depending on how the scenario evolves, modifications were made to address any learning needs that arise. In this session, residents were taught around what to expect clinically from each infarct territory, the importance of serial EKGs, and the management of cardiogenic shock in the context of an acute MI. Considerations, such as the use of small boluses, vasopressor initiation, and when to consult a specialty service were also covered. The use and contraindications of TNK and intubation techniques were discussed. An approach to chest pain, including a differential diagnosis of noncardiac causes of chest pain was also discussed. Additional objectives may be included by individual facilitators depending on local goals of the session. In cases such as this where transfer may be required, there is an opportunity to discuss local protocols and considerations such as weather and resource management.
Modifiers for the case can be applied in a variety of ways to both adjust difficulty and allow repeated use of the case, highlighting different points at each encounter. Some such modifications are included in Table 2. One such modification could include death as the end scenario. Currently, there exists much discussion about the benefits of including death as an outcome in simulationbased medical education [17][18]. Depending on learner objectives, facilitators could include an unsuccessful resuscitation as an optional end to the case.

Feature Modifier and Comments
Simulated patient confederates

TNK -tenecteplase
A 90-minute didactic teaching session was also included to provide further teaching on topics relating to the case objectives. The incorporation of teaching following the simulation has been shown to be superior to pre-simulation instruction alone [10]. This was broken down into 45 minutes immediately following the scenario and an additional 45 minutes in a separate teaching session the following morning.

Product
The expected learning outcomes for each participant are outlined by the learning objectives for this case:

ACS -acute coronary syndrome
Following the scenario, an anonymous survey is circulated to all participants. This allows the facilitators to gather feedback from the participants over the next few days following the session. Examples of questions circulated are included in Table 4.

Discussion
In over 70% of cases, cardiogenic shock is related to acute myocardial infarction with ST-segment elevation. The management of acute MI with or without cardiogenic shock is crucial for anyone practicing acute care medicine -both in rural and urban centres.
For example, medical trainees across multiple disciplines often have to complete off-service rotations in which on-call coverage of a medical floor is necessary. Therefore, the quick recognition and management of acute coronary syndrome, including acute myocardial infarction and cardiogenic shock is imperative.
Physicians practicing in rural locations tend to have broad scopes of practice and as such are responsible for managing such presentations until transfer to a tertiary care centre can be arranged [19][20]. Local considerations, such as weather, mode of transport, and resource availability become important and are easily included in the scenario.
This scenario was initially run in small groups (three to four learners per session) of rural family medicine residents and medical students. Scenario subject and learning objectives were not distributed prior to the session. Learners were encouraged to use any available resourcesincluding books, ACLS algorithms, and web applications -during an emergency department or call shift. The didactic session focused largely on the aforementioned learning objectives, and a written handout was circulated to learners following the session. A second teaching session, within the subsequent two weeks, was held to incorporate some Point of Care Ultrasound (PoCUS) teaching around echocardiography. Feedback on the scenario was largely positive, in particular surrounding the management of cardiogenic shock. There were suggestions around in situ simulation of this case rendering it more realistic, but unfortunately, that was not possible at the time of the sessions. Instead, future sessions will incorporate some other allied health care professionals (including nursing and respiratory therapy) to work on team functioning along with the scenario.
Future work includes validation of the locally developed GRS as the simulation is repeated over time with different learners. This would allow for the provision of objective feedback to the learner in a structured approach. As well, this scenario is a part of a larger curriculum developed for rural and remote trainees and will evolve as required to reflect local learning objectives.
The development of this scenario in a step-wise fashion allows the simulation to react according to learner actions. The list of modifiers included in Table 2 allows for an easily adaptable scenario that can be repeated according to local learning objectives. Having a facilitator review the scenario in advance ensures that it is of reasonable difficulty for the intended learner group and allows instructors to identify any shortcomings of the scenario. Finally, the coupling of a formal debriefing with a didactic learning session allows for both the collaborative identification of knowledge gaps and process errors that may arise during the scenario.

Conclusions
The use of simulation in teaching rural medicine trainees to manage acute myocardial infarction and cardiogenic shock may close a learning gap. These situations can be very demanding and emotionally charged. Therefore, practice in a controlled environment can be beneficial for rural family medicine trainees, ultimately improving both learner comfort and patient outcomes. We have presented herein an acute STEMI with cardiogenic shock, along with scenario modifiers, and post-scenario didactics and teaching, designed for rural family medicine trainees.