EMRA Simulation Guide

How to Use This Guide

For ABEM Oral Board Examination Review

These cases are written so they may be utilized in myriad formats. You may use these cases systematically to help prepare for the oral board examination, or you may elect to use these cases to develop your fund of knowledge.

About the Examination
In late 2020, the format of the ABEM Oral Board Examination was modified to include multiple single-patient encounters and structured interviews. Prior to the examination, you should take time to review the sample single-patient encounter videos found on the ABEM webpage. These cases will require you to progress through patient care in a conventional format, as you would in real life. The structured interview is designed to delve further into your thought process. An examiner may ask you why you requested a particular study or performed a certain component of the physical examination, request your top 3 differential diagnoses, or ask you to explain the disposition of the patient. The examiner simply wants to understand your reasoning. Unlike in the single-patient encounter, you are speaking with the examiner directly rather than to the patient or simulated nurse. Essentially, you will speak through a single-patient case in a more academic style where the examiner will progress the case as necessary. You have 15 minutes to complete each case, including all the critical actions. You will likely have one additional case that is experimental only.

Evaluation and Scoring
Prior to your oral board examination, refer to the ABEM webpage for a document titled "Detailed Performance Criteria: Oral Exam"

The evaluation criteria include:

• Data Acquisition
• All critical data points must be obtained
• An orderly and timely approach to data acquisition must exist
• The approach must be integrated into the management plan
• Problem-solving
• Consider appropriate alternative diagnoses and work through the differential in an appropriate and prioritized fashion
• Stabilize and manage the patient efficiently and appropriately
• Patient management
• Appropriate and timely care provided with anticipation of future care-related issues
• Resource Utilization
• Ordered relevant studies to work through appropriate differential diagnoses
• Demonstrated logical resource use
• Health Care Provided (Outcome)
• Standard of care was followed in present time
• How the patient did overall
• Interpersonal relations and communication skills
• Spoke with staff, patient, EMS, and other scenario-specific bodies with respect
• Explained plan to patient or family
• Made the patient and/or family feel comfortable
• Comprehension of pathophysiology
• Clinical Competence (overall)

Practicing the Format

Having a systematic approach to each case is critical for the oral board examination. This is both in terms of information acquisition and information processing. Work through the cases with an idea of how you want to gather information each time (please refer to the sample cases for one example of how to do this). Keep track of the information you gathered by setting up your blank sheet of paper the same way each time. This way, you are able to quickly reference the information you need as the case progresses and can ensure no critical actions are missed.

Solo Practice
You may choose to read through the cases on your first pass through this guide.  However, you may find it even more helpful to quiz yourself as you move through the cases. Ask yourself, “What do I see, hear, and smell?” as you start a case and reveal only the next pertinent piece of information.  Verbalize as you would if an examiner was sitting across from you. At the end of each case, review the list of critical actions and ensure you have an understanding. 

Partner Practice

For Simulation Practice

For simulation, there will be medical team and ancillary actors needed to run the case. All roles should be assigned prior to the start of the case. Multiple roles can be played by one individual if the need presents. The roles are outlined below.

• Consultants: This individual should either guide the pre-clinical student/intern with fund of knowledge (eg, ECG interpretation), serve as the defining clinical intervention (eg, surgical management), or to accept the patient for admission to the service. Should prompt team members for 1-2 line patient summary and reason for consult if not provided.
• Case Manager: This individual will run the case and should start by providing a one-line statement of the patient’s age and reason for presentation. Those participating in the case should be allowed to extract pertinent history from either a) the patient, b) the family/caretaker, or c) EMS. If participants fail to obtain a history from parties other than the patient (including previous medical records), the case manager should gently prompt the team after some time has passed.

Additionally, the case manager will be responsible for reporting vital signs as they evolve with the case. Vital signs in the sample cases will have parentheses indicating what repeat vitals should be after the recommended intervention.  If participants ask for repeat vitals after no intervention, the case manager should provide the initial set of vitals again (except in cases where the patient may have decompensated without acute intervention). If the participants use a different intervention other than the recommended intervention, the case manager may take creative license to vary the repeat vitals and flow of the case.

Physical exam findings are also documented in the sample cases. The participants should attempt to perform a physical exam and should specifically ask for each finding. For instance, if a participant is performing the abdominal exam, the participant should specifically ask, “What do I hear?” and “Is the patient tender to palpation?” while pantomining the motion. If the team asks overly broad questions, the case manager should guide them to clarify/specify. If the team member omits a portion of the physical exam, the case manager should not reveal it until directly prompted by the team members. 

Laboratory values will be reported to the case manager as well. The case manager should simply omit the results of any extraneous labs ordered by participants. Lab values should be revealed one to two minutes after the initial request. Whether all the lab values are revealed simultaneously or in batches is at the discretion of the case manager. It may be helpful to print laboratory values for participants or to display them on a screen when first starting simulation exercises.

Similarly, the case manager should also display imaging results (whether in print or electronically). Representative imaging has been provided in the sample cases, and participants should be responsible for interpreting the imaging. If they are unable to do so, the case manager may prompt them to consult the radiologist. Although this is not the most realistic representation, this guide is designed to expose any level of participant to simulation despite fund of knowledge limitations. 

Finally, critical actions will be listed at the end of each case. The case manager should take care to review these critical actions prior to the start of the case to guide the flow the case. With this guide, efforts have been taken to ensure that the sample cases do not have too many variations, complexities, or unexpected turns that would be more appropriate for the advanced student or resident. This is reflected in the critical actions checklist.

Note: Some participants have found it beneficial to program a handheld tablet device or a laptop computer to display the vitals, rhythm strip, etc. This is at the discretion of the case manager.

• Nurse: Team members should ask the nurse to start peripheral IV lines with statement of specific gauge if possible. Team members should also directly ask nurses to draw laboratory studies. If necessary, nurses can assist with chest compressions but should be directed to do so by the particpants.
• Family/EMS: This individual may be responsible for reporting parts of the history of present illness and should thus refer to the case manager role in terms of imparting information from the history. At times, the family member may take free license with the role to be distracting or to appear emotionally upset for the team to best approach and handle the situation.
• Debrief Manager: This role is further elaborated in the debriefing section. This individual should review the critical action steps and make note of which actions were performed and which were omitted. This individual should also take notes throughout the duration of the case to assess areas of expertise and areas for improvement. At the end of the allotted time for the case or at the team’s resolution of the case (which ever comes first), the debrief manager should signal the cessation of the simulation exercise.

Team
For the purpose of simulation, teams for each case are particularly useful.

Most teams are composed of 4-5 participants in order to allow each student/resident to have a distinct role and learning opportunity. Groups should be encouraged to assign roles for the purpose of improved communication, clearly defined tasks, and overall organization. Suggested roles are as follows but are quite fluid and can be shifted around as needs change. Participants are encouraged to rotate roles at the end of each case.

• Team Leader: This individual should synthesize the information provided by all the team members and should summarize the case + interventions every so often, initiate discussion of differential diagnoses, and make the definitive decision for interventions.
• History/Labs/Imaging/Consults: This individual should extract the history of present illness from the patient, family, or EMS. Then findings should be shared with the team and specifically the team leader. Any labs or imaging that need to be ordered should be done by this person, and any results of these tests should be reported back to this person. Any consults needed should be called by this team member starting with a brief summary of the case to that point (1-2 lines) and a reason for consult.
• Airway/Procedure: This person is largely responsible for ensuring the airway is maintained. Any other procedures that arise such as central lines, arterial lines, etc. should also be conducted by this individual. In a case warranting chest compressions, this participant may rotate responsibility for the airway with the “Physical Exam/Compressions” team member.
• Physical Exam/Compressions: This individual’s role is to perform the primary and secondary survey (which includes a head-to-toe physical exam). In trauma cases, this individual should ask the “Airway/Procedure” team member to initiate the count for rolling so that further physical exam may be conducted. Additionally, this team member is responsible for running a LifePak device, obtaining EKGs, and asking for updated vital signs.

For the actual set-up of the case, please refer to the beginning of each sample case. This will list recommended environment (to rule in need for scene safety), any drastic change in the appearance of the actor or mannequin that should be disclosed to the team (eg, trauma), and other equipment or props. In some cases, not all of the equipment or props will be utilized.

Additionally, in non-obstetric and non-trauma cases, ultrasounds should not be considered a mandatory test (unless it is first-line standard imaging).