Resuscitative Hysterotomy

This weeks’ case was written by Dr. Amy Hildreth who is an emergency physician and assistant program director for the EM residency at Naval Medical Centre in San Diego.

Why it Matters

Resuscitative hysterotomy is fortunately a rare procedure, however, as with other high impact, low occurrence procedures in emergency medicine, it can be life saving! Equally as important as the procedure itself are the crisis resource management (CRM) components involved in managing two critically ill patients; the mother and the baby.

This case was designed to highlight the management of a pregnant trauma patient, the procedure of resuscitative hysterotomy, and the CRM principles involved. It is not for the faint of heart!

Clinical Vignette

A 30 y/o female was found unresponsive in an SUV that rolled over after being side swiped on the highway going approximately 70 mph (~110kph). The patient has a large, gravid abdomen and, as she was wheeled into the resuscitation bay, the pulse was lost.

Case Summary

The team receives advance notification from EMS about a 30 year-old female who is visibly pregnant and was in a car accident. Upon arrival to the ED the patient loses pulses and CPR begins. The team must begin ACLS/ATLS and proceed to resuscitative hysterotomy. After delivery they should begin neonatal resuscitation and continue management of the mother.  Early consultation should be made to trauma surgery, NICU, and OB. 

Download the case here: Resuscitative Hysterotomy

Learner-Consultant Communication

This case was written by Dr. Jared Baylis. Jared is currently a PGY-4 in emergency medicine at UBC (Interior Site – Kelowna, BC) and is completing a simulation fellowship in Vancouver, BC.

Twitter – @baylis_jared + @KelownaEM

Why It Matters

Referral-consultant interactions occur with regularity in the emergency department. These interactions are critically important to safe and effective patient care. Several frameworks have been developed for teaching learners how to communicate during a consultation including the 5C, PIQUED, and CONSULT models. This case allows simulation educators to incorporate whichever consultation framework they prefer into a simulation scenario that allows deliberate practice of the consultation process.

Clinical Vignette

You are a junior resident working in a tertiary care centre and you are asked to see a 58-year-old female patient who was sent in from the cancer centre. She is known to have metastatic non-small-cell lung cancer and has been increasingly dyspneic with postural pre-syncope over the last few days. Her history is significant for a previous malignant pericardial effusion that was drained therapeutically a few months ago.

Case Summary

In this case, learners will be expected to recognize that this 58-year-old female patient with metastatic non-small-cell lung cancer has tamponade physiology secondary to a malignant pericardial effusion. The patient will stabilize somewhat with a gentle fluid bolus but the learners will be expected to urgently consult cardiology or cardiac/thoracic surgery (depending on the centre) for a pericardiocentesis and/or pericardial window.

Download the case here: Learner-Consultant Communication

Checklists for 5C, PIQUED, and CONSULT frameworks: Consult Framework Checklists

FOAMed article on 5C framework: 5C CanadiEM

FOAMed article on PIQUED framework: PIQUED CanadiEM

ECG for the case found here:


(ECG Source:

CXR for the case found here:


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POCUS for the case found here:


(Ultrasound Source:

Newborn Resuscitation

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

Approximately 10% of newborns require some degree of resuscitation upon delivery, with less than 1% requiring active resuscitation.1 Given that deliveries in the ED are relatively rare, this means that performing NRP in the ED is quite uncommon. On the other hand, the ED team must be able to respond quickly and efficiently to a flat neonate. This means that practising NRP is paramount – and what better way to do so than with simulation! This case highlights three key pieces of NRP, including:

  • The need to warm, dry, and stimulate immediately
  • The quick progression to positive pressure ventilation if stimulation doesn’t work
  • When to initiate CPR, the necessary 3:1 compression:ventilation ratio, and how to place hands for performing CPR on a neonate

Clinical Vignette

You are working in the minor area of your ED and have been called by the physician on the major side to assist with a precipitous delivery. He is managing the mother and wants you to be ready to resuscitate the infant if needed. The mom thinks she’s term. She’s had no prenatal care and is an IV drug user. She used earlier today. There no meconium staining noted in the amniotic fluid. Baby has just been delivered and is handed to your team.

Case Summary

The team has been called to help in the ED where a woman just precipitously gave birth to a baby now requiring resuscitation. The mom thinks she’s at term. She has had no prenatal care and is an iv drug user. The baby will be flat. After stimulation and drying, the baby will have a HR <100 and PPV will be required. After 60 seconds, the HR will still be <60 and CPR will need to be started. This will be short lived. The team will also need to intubate and obtain IV access.

Download the case here: NRP Case


  1. Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics2006;118:10281034doi: 10.1542/peds.2006-0416

Multi-Trauma: Blunt VSA and Burn

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

This case is an excellent example of the challenges faced in Emergency Medicine. Not only are learners faced with a worst-case airway scenario, but they must also manage two critically ill patients at once. In particular, it draws attention to the following:

  • The need to plan for and manage resources appropriately when faced with two critically ill patients simultaneously
  • The importance of recognizing and adequately preparing for a difficult airway
  • The acknowledgement of a failed intubation/ventilation scenario requiring expedient placement of a surgical airway

Case Summary

The case will start with an EMS patch indicating that they are 2 minutes out with multi-trauma from a 2 car MVC. Two patients will then arrive within 1 minute of each other. The first will have gone VSA en route from presumed blunt trauma. This patient will not regain a pulse. The second patient will arrive with significant burns from a car fire, and will have GCS of 3 necessitating intubation. All attempts at intubation will be unsuccessful, and a surgical airway must be performed. The team will need to prioritize resources between the two patients and realize that an ED thoracotomy is not reasonable in the first patient.

Clinical Vignette

Before first patient:

You are working in a tertiary care trauma center. EMS patch: We have a 50ish M unbelted driver in a head-on MCV at about 60km/hr. He was ejected from the vehicle and found about 30m from the crash site with a GCS of 3. He has an obvious head injury, torso injury and unstable pelvis, which we’ve bound. Initially had RR 40, O2 85% on NRB, HR 150 and a questionable femoral pulse. Since then, he’s been pulseless. We’ve been en route about 5 minutes and should be there in about 2 min. He’s received 1mg Epi so far with no shocks advised x2. Smells of EtOH, but no other known history. There was one other car involved that caught on fire, so you’ll probably get them, too, if they survive. Please prepare for this patient.

Upon arrival of second patient:

EMS Handover: This 30ish male belted driver was in a head on MVC with both cars going ~60km/hr. His car was on fire when we got there, and he’s got 2nd/3rd degree burns everywhere. We found him outside the car, so he must have self-extricated. His GCS has been 3 the entire time with us. He’s tolerating an oral airway. His last vitals were HR 120, BP 130/80, RR 30, O2 95% NRB

How to Run the Case

At McMaster University, we successfully ran this case with our PGY4 residents. To do so, we had two confederate nurses at the bedside (one nurse per patient). We also had dedicated sim techs running each mannequin. Finally, we had three faculty instructors. One instructor to observe the management of each patient, and one instructor to play the role of the arriving paramedic and to coordinate between the two instructors and sim techs. We are able to run the case with four of our emergency medicine resident learners playing the roles of a trauma team (one team leader, one senior emerg resident, one senior anesthesia resident, and one surgical resident). It went very well and received positive feedback from the learners. Of note, this case is ripe with opportunity for incorporating other learners. In particular, inter-professional education using ED nurses, RT’s, and learners from other services could work as well.


Download the case here: Multitrauma Cric and Blunt VSA Case

Cardiac U/S for Patient 1 found here*:

FAST for Patient 1 found here:


ECG for Patient 2 found here:


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Pre-intubation CXR for Patient 2 found here:

Normal CXR Male

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PXR for Patient 2 found here:


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Post-intubation CXR for Patient 2 found here:

Normal Post-Intubation CXR

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Cardiac U/S for Patient 2 found here*:

FAST for Patient 2 found here*:

no FF

Lung U/S for Patient 2 found here*:

*All U/S images are courtesy of McMaster PoCUS Subspecialty Training Program.

How to develop targeted simulation learning objectives – Part 2: The Practice

In part 1 of this two part series (, we used the revised Bloom’s taxonomy to describe an approach to developing simulation-based learning objectives by targeting a specific, complex knowledge domain and a higher level cognitive process.

Now that we know the theory behind making targeted simulation learning objectives, what kind of learning objectives should be included in a team-based resuscitation simulation scenario?

Team based simulation can be used to learn and assess a variety of different components of resuscitation skills. These simulated events display the knowledge, skills and attitudes of learners in a controlled setting. What makes simulation different from other traditional models of learning is that it combines components of crisis resource management (CRM) with medical knowledge and skills into a complex educational event. Keeping this in mind, while developing objectives for a simulated scenario, it helps to separate the CRM and medical knowledge objectives. A separation of these two key components allows for targeted feedback directed at specific areas of the learners’ performance and aids in their assessment.

A common pitfall in the development of objectives for a simulated case is including too many of them! While there are a multitude of soft skills as well as medical decisions being made during the simulated event, both the learners and assessors benefit from having a limited amount of clear objectives. Debriefing after a simulation is critical for the learning experience and having too many objectives may dilute the main teaching points of the case. As an example, at the McGill University Emergency Medicine residency program, we aim for 2 CRM based objectives and 3 medical knowledge objectives. While this is in no way the rule, we have found that tailoring the case to a smaller number of clear and well-developed objectives allows for productive and high yield debriefing sessions.

Learning Objectives for a Tricyclic Antidepressant Overdose Case

Learning Objectives for a Tricyclic Antidepressant Overdose Case

As discussed in a previous post (, the main components of CRM include communication, leadership, resource utilization, situational awareness and problem solving.1 A case can be specifically tailored toward a CRM objective or vice versa. For example, an objective focusing on resource utilization and triage can guide the development of a simulated case with two patients in a resource-limited setting. Conversely, a simulated STEMI case can include an objective focusing on leadership and the team leader maintaining a global perspective of the case. There are no guidelines on which CRM based objectives to include, but ensuring that your cases utilize different CRM components allows your learners to focus on a few important skills at a time and ensures that your learners are exposed to each component of CRM in a simulated setting.

Medical objectives encompass the core medical content that the simulated case was designed to address. When developing the medical objective, remember to focus on a higher cognitive process, such as “applying” over “remembering”, and a higher-level knowledge domain, such as “procedural knowledge” that includes skills and algorithms. Again, there is no limit to what medical objectives you can include, as long as they are well developed and specific. When developing the medical objective for the case, it may help to take a step back and ask yourself “what do I want my learners to take away from this case?” It also helps to consider the training level of the learners, where simulation fits within your full educational curriculum as well as your setting and to develop the objectives accordingly. As an example, an airway case may contain an objective on the choice of an induction and paralytic agent for intubation for junior learners, whereas an objective on a “can’t intubate, can’t ventilate” situation may be more suitable for senior learners.

Defining learning objectives for your simulated scenarios is key for case development, debriefing and, ultimately, learning. Using theory, we can create targeted objectives that optimize the learning time spent in the simulated setting. Breaking up the objectives into CRM and medical knowledge while limiting the total number of objectives can help focus both the learner and educator on the teaching points from the case. Through careful consideration of learning objective development, simulation can be used to both fill potential gaps in you educational curriculum and to enhance the resuscitation skills, CRM skills and medical knowledge of your learners.

Take Home Points

1) Divide simulation objectives into CRM or medical objectives

2) Limit the number of objectives for each case

3) Apply theory to develop targeted and specific objectives to align them with the teaching strategy of simulation

4) Diversify your CRM objectives throughout your simulation curriculum

5) For medical objectives, ask yourself “what do I want my learners to take away from this case?”

6) Consider the training level, full training curriculum and setting when developing medical objectives.

  1. 1) Hicks CM, Kiss A, Bandiera GW, Denny CJ. Crisis Resources for Emergency Workers (CREW II): Results of a pilot study and simulation-based crisis resource management course for emergency medicine residents. Can J Emerg Med. 2012;14(Crew Ii):354-362. doi:10.2310/8000.2012.120580.

Crisis Resource Management

What is CRM?

Crisis Resource Management refers to the extremely important but sometimes difficult to define “soft skills” that can make or break the function of a team. The concept was originally developed by the airline industry in response to research demonstrating that the large majority of airplane crashes occurred due to failures of the crew to effectively utilize resources. In this case, CRM referred to Crew Resource Management, which was a type of training designed to address these issues. Eventually, these ideas were brought to medicine by Gaba, Howard, Fish et al, who developed a curriculum for anesthesiologists.1 This group changed the name of the training to Crisis Resource Management, and the medical field has been calling it crisis resource management ever since.

Being able to identify and label the skill components of CRM helps a simulation educator immensely. It is essential to address these skills during debriefing. In fact, cases can be designed specifically to elicit these skills.

The main components of CRM


1) Communication

This should be no surprise. Communication is a basic tenant of good team function in any environment. Classically, good communication during a resuscitation is referred to as “closed loop communication.” This means 1) Clearly identifying who is being spoken to and delegating a clear, specific task to that person. 2) The recipient acknowledging what has been heard. 3) The recipient clearly stating when the delegated task has been completed. This stage is referred to as “closing the loop” on the initial order. Notice that the loop described is for one order. A common communication pitfall is to call out too many orders at once. Quality communication also means listening to suggestions and updates from team members and respectfully acknowledging them.

2) Leadership

There are many ways for the team leader to lead a case. The style of leadership is less important than the fact that there is leadership. Clear communication is part of this. But so is maintaining order and calm in the room, sharing your mental model with the team, and soliciting feedback and ideas from the team. Common pitfalls include not clearly establishing leadership during a resuscitation or having a leader that is not receptive to input from team members.

3) Resource allocation

This refers to the ability to optimize the roles and use of available personnel and equipment. A common pitfall of resource allocation is to forget that there are other resources in the room or outside the room. Does the team leader need to be the person intubating? Does the team leader notice that the medical student is standing in the corner while the nurse doing CPR is getting tired? Would the nurse be of more help administering medications and obtaining IV lines? Do the members of the team ask for help when they need it? Does the team change the monitor to cycle the blood pressure every two minutes instead of every fifteen when the patient status changes from well to unwell?

4) Situational awareness

This refers to the ability of the learner to perceive the many components of their environment. More importantly, it specifically addresses their understanding of what those components mean when combined to one whole. Does the learner recognize that they administered a medication and the patient’s blood pressure immediately dropped? When the patient starts wheezing and the oxygen saturations also drop, does the learner recognize that this could be a consequence of their medication administration? Does she even notice the change in vital signs? Debriefing around situational awareness often involves addressing a failure to recognize a problem, fixation on a single diagnosis or problem, (to the detriment of other possibilities or concurrent problems that require management) or failure to anticipate new problems or complications that may arise as a result of the illness or its treatment.

5) Problem solving

This concept describes the process by which a learner must create a solution to a situation in which there is no routine answer. The process of developing a novel solution can be fraught with cognitive errors. Unpacking these errors can be a very valuable part of debriefing. It is important to note that for very junior learners, almost all situations are unique problems to be solved. (And hence, scenarios often do not need to be particularly complex.) More senior learners require more complex cases simply because they have a broader scope of familiar experiences. In order to challenge their problem solving, one must introduce them to an unexpected complication or a novel patient situation.


These resources all describe the five CRM components listed above. They also look to the assessment of CRM skills.

  1. Gaba DM, Howard SK, Fish KJ, Smith BE, Sowb YA. Simulation-Based Training in Anesthesia Crisis Resource Management (ACRM): A Decade of Experience. Simul Gaming. 2001;32(2):175-193. doi:10.1177/104687810103200206.
  2. Gaba D, Howard S, Fish K. Crisis management in anesthesiology. New York: Churchill Livingstone Publishers; 1994.
  3. Kim J, Neilipovitz D, Cardinal P, Chiu M. A comparison of global rating scale and checklist scores in the validation of an evaluation tool to assess performance in the resuscitation of critically ill patients during simulated emergencies (abbreviated as “CRM simulator study IB”). Simul Healthc. 2009;4:6-16. doi:10.1097/SIH.0b013e3181880472.
  4. Hicks CM, Kiss A, Bandiera GW, Denny CJ. Crisis Resources for Emergency Workers (CREW II): Results of a pilot study and simulation-based crisis resource management course for emergency medicine residents. Can J Emerg Med. 2012;14(Crew Ii):354-362. doi:10.2310/8000.2012.120580.