- Emergency Medicine
Clinical Associate Professor, Emergency Medicine
Emergency Medicine Director of Simulation, Dept. of Emergency Medicine (2019 - Present)
Emergency Medicine Simulation Fellowship Director, Dept. of Emergency Medicine (2016 - Present)
Honors & Awards
Outstanding Educator Award, Stanford Department of Emergency Medicine (2019)
Quarterly Bedside Teaching Award, Stanford-Kaiser Emergency Medicine Residency Program (2011)
Bedside Teaching Award, Stanford-Kaiser Emergency Medicine Residency Program (2014)
Boards, Advisory Committees, Professional Organizations
Fellow, American College of Emergency Physicians (2012 - Present)
Member, Fellowship Approval Committee, Society for Academic Emergency medicine (2018 - Present)
Board of Directors, Simulation Academy, Society for Academic Emergency Medicine (2017 - 2019)
MS, University of Alabama-Birmingham, Healthcare Simulation (2021)
Residency: Stanford University Medical Center (2008) CA
Board Certification: American Board of Emergency Medicine, Emergency Medicine (2009)
Medical Education: Pennsylvania State University (2005) PA
Current Research and Scholarly Interests
Interests include simulation for procedural training, faculty development, and teamwork.
Undergraduate Classes - Introduction to the Management of the Ill Patient, Stanford University School of Medicine
Creating a Safe Space for Simulation: Is it Time to Stop Calling Them Confederates?
Simulation in healthcare : journal of the Society for Simulation in Healthcare
Use of the term "confederate" is often used in research literature to describe an individual allied with the research team. Confederate is used in simulation research to describe participants allied with the simulation facilitator. Confederate can also refer to the Confederate States of America and has connotations of racial injustice and slavery. Use of this term in simulation may adversely affect psychological safety of learners. Use of the term within the literature is a potential driver of use during simulation sessions. We completed a rapid review of the health care simulation literature to determine the frequency of the term confederate. From 2000 to 2021, 2635 uses of confederate were identified in 765 articles. There seems to be an increased trend in use of this word. We argue that alternative terms exist and should be used to maximize psychological safety of learners.
View details for DOI 10.1097/SIH.0000000000000710
View details for PubMedID 36455290
19-Year-Old with Sudden Onset Left Testicular Pain.
Clinical practice and cases in emergency medicine
2022; 6 (4): 327-329
A previously healthy 19-year-old man presented to the emergency department with severe, sudden onset of left testicular pain. Physical exam revealed a left high-riding, horizontally oriented testicle without cremasteric reflex. Point-of-care ultrasound was used to confirm the diagnosis of testicular torsion, as well as to guide manual detorsion, verifying return of blood flow after reduction.Testicular torsion is a urologic emergency in which testicular viability is time dependent. Point-of-care ultrasound can be an important and helpful tool to not only confirm suspicion but help guide adequacy of blood flow return after manual detorsion in conjunction with comprehensive ultrasound.
View details for DOI 10.5811/cpcem.2022.7.56747
View details for PubMedID 36427024
The OSSE: Development and validation of an "Objective Structured Supervision Evaluation".
AEM education and training
2022; 6 (4): e10784
Trainee supervision and teaching are distinct skills that both require faculty physician competence to ensure patient safety. No standard approach exists to teach physician supervisory competence, resulting in variable trainee oversight and safety threats. The Objective Structured Teaching Evaluation (OSTE) does not adequately incorporate the specific skills required for effective supervision. To address this continuing medical education gap, the authors aimed to develop and identify validity evidence for an "Objective Structured Supervision Evaluation" (OSSE) for attending physicians, conceptually modeled on the historic OSTE.An expert panel used an iterative process to create an OSSE instrument, which was a checklist of key supervision items to be evaluated during a simulated endotracheal intubation scenario. Three trained "standardized residents" scored faculty participants' performance using the instrument. Validity testing modeled a contemporary approach using Kane's framework. Participants underwent simulation-based mastery learning (SBML) with deliberate practice until meeting a minimum passing standard (MPS).The final instrument contained 19 items, including three global rating measures. Testing domains included supervision climate, participant control of patient care, trainee evaluation, instructional skills, case-specific measures, and overall supervisor rating. Reliability of the assessment tool was excellent (ICC range 0.84-0.89). The assessment tool had good internal consistency (Cronbach's α = 0.813). Out of 24 faculty participants, 17 (70.8%) met the MPS on initial assessment. All met the MPS after SBML and average score increased by 19.5% (95% CI of the difference 10.3%-28.8%, p = 0.002).
View details for DOI 10.1002/aet2.10784
View details for PubMedID 35903423
View details for PubMedCentralID PMC9305721
- The OSSE: Development and validation of an "Objective Structured Supervision Evaluation" AEM EDUCATION AND TRAINING 2022; 6 (4)
From intern to "accepted": A guide to preparing for fellowship in emergency medicine.
AEM education and training
2022; 6 (Suppl 1): S23-S31
The number of fellowship options for emergency medicine (EM) physicians continues to expand. While guides exist to help residents explore individual fellowship pathways, we aimed to create a comprehensive guide for all residents considering fellowship.At the direction of the Society for Academic Emergency Medicine (SAEM) Board, 9 members of the Fellowship Guide Workgroup, including members of the Fellowship Approval Committee, and 2 members of SAEM Residents and Medical Students (RAMS) group collaboratively developed the guide using available evidence and expert opinion when high-quality evidence was unavailable. The guide was reviewed and approved by all members.The guide offers advice to EM residents on how to conceptualize key aspects of their training with respect to preparation for fellowship, including scholarship, teaching, leadership, and electives. Additionally, it offers perspective on selecting a fellowship that matches the resident's interests and goals and successfully applying.This fellowship guide for EM residents considering fellowship summarizes the best currently available advice for residents considering fellowship training after residency.
View details for DOI 10.1002/aet2.10751
View details for PubMedID 35783084
View details for PubMedCentralID PMC9222866
- From intern to "accepted": A guide to preparing for fellowship in emergency medicine AEM EDUCATION AND TRAINING 2022; 6: S23-S31
A mixed-methods needs assessment to identify pharmacology education objectives for emergency medicine residents.
Journal of the American College of Emergency Physicians open
2022; 3 (2): e12682
Objectives: Medication errors represent a significant threat to patient safety. Pharmacotherapy is one of the 23 Accreditation Council of Graduate Medical Education milestones for emergency medicine, yet there is minimal understanding of what content should be prioritized during training. The study aim was to develop objectives for a patient-safety focused pharmacology curriculum for emergency medicine residents.Methods: We incorporated data from a de-identified safety event database and survey responses of 30 faculty and clinical pharmacists at a single-site suburban university hospital with 24-hour emergency medicine pharmacists and an annual volume of approximately 70,000. We reviewed the database to quantify types and severity of medication errors over a 5-year period for a total of 370 errors. Anonymous surveys included categorical items that we analyzed with descriptive statistics and short answer questions that underwent thematic analysis by 2 coders. We summarized all data sources to identify curriculum gaps.Results: Common medication errors reported in our database were wrong dose (43%) and computer order entry errors (14%). Knowledge gaps were medication cost (63%), pregnancy risk information (60%), antibiotic stewardship (53%), interactions (47%), and side effects (47%). Qualitative analysis revealed the need to optimize computer order entry, understand the scope of critical medications, use references, and consult pharmacists. Integration of data suggested specific medications should be covered in curricular efforts, including antibiotics, analgesics, sedatives, and insulin.Conclusion: We developed objectives of pharmacology topics to prioritize during emergency medicine training to enhance prescribing safety. This study is limited due to its small sample and single institution source of data. Future studies should investigate the impact of pharmacology curriculum on minimizing clinical errors.
View details for DOI 10.1002/emp2.12682
View details for PubMedID 35310405
Assessment of Entrustable Professional Activities Using a Web-Based Simulation Platform During Transition to Emergency Medicine Residency: Mixed Methods Pilot Study.
JMIR medical education
2021; 7 (4): e32356
BACKGROUND: The 13 core entrustable professional activities (EPAs) are key competency-based learning outcomes in the transition from undergraduate to graduate medical education in the United States. Five of these EPAs (EPA2: prioritizing differentials, EPA3: recommending and interpreting tests, EPA4: entering orders and prescriptions, EPA5: documenting clinical encounters, and EPA10: recognizing urgent and emergent conditions) are uniquely suited for web-based assessment.OBJECTIVE: In this pilot study, we created cases on a web-based simulation platform for the diagnostic assessment of these EPAs and examined the feasibility and acceptability of the platform.METHODS: Four simulation cases underwent 3 rounds of consensus panels and pilot testing. Incoming emergency medicine interns (N=15) completed all cases. A maximum of 4 "look for" statements, which encompassed specific EPAs, were generated for each participant: (1) performing harmful or missing actions, (2) narrowing differential or wrong final diagnosis, (3) errors in documentation, and (4) lack of recognition and stabilization of urgent diagnoses. Finally, we interviewed a sample of interns (n=5) and residency leadership (n=5) and analyzed the responses using thematic analysis.RESULTS: All participants had at least one missing critical action, and 40% (6/15) of the participants performed at least one harmful action across all 4 cases. The final diagnosis was not included in the differential diagnosis in more than half of the assessments (8/15, 54%). Other errors included selecting incorrect documentation passages (6/15, 40%) and indiscriminately applying oxygen (9/15, 60%). The interview themes included psychological safety of the interface, ability to assess learning, and fidelity of cases. The most valuable feature cited was the ability to place orders in a realistic electronic medical record interface.CONCLUSIONS: This study demonstrates the feasibility and acceptability of a web-based platform for diagnostic assessment of specific EPAs. The approach rapidly identifies potential areas of concern for incoming interns using an asynchronous format, provides feedback in a manner appreciated by residency leadership, and informs individualized learning plans.
View details for DOI 10.2196/32356
View details for PubMedID 34787582
- Rapid Cycle Deliberate Practice in Virtual Reality: Teaching Transvenous Pacemaker Insertion to Emergency Medicine Residents CUREUS 2021; 13 (10)
Rapid Cycle Deliberate Practice in Virtual Reality: Teaching Transvenous Pacemaker Insertion to Emergency Medicine Residents.
2021; 13 (10): e18503
Introduction Transvenous pacemaker insertion is a critical life-saving procedure that is infrequently performed. Traditional mannequin-based training paradigms are resource intensive and sometimes inadequate due to time constraints. Rapid Cycle Deliberate Practice (RCDP) is an effective teaching modality for highly scripted procedures. We propose using a simulation-based technique of RCDP in virtual reality (VR) to teach this procedure. Methods Sixteen emergency medicine residents were recruited. A pre-survey was administered at the start of the session, followed by a baseline task trainer checklist-based assessment. This checklist was created based on expert consensus. Participants then underwent the RCDP VR intervention with a subsequent repeat checklist-based assessment as well as a post-survey. Results Post-test scores were found to be significantly higher than pre-test scores after residents completed VR deliberate practice simulation (19.5±3.5 vs 24.1±2.0; p<0.001). Subanalysis did not reveal any significant difference based on post-graduate year, previous performance of procedure on a live patient, or previous VR experience. The experience increased participant feelings of preparedness and comfort in performing the procedure (2-disagree vs 4-agree) based on a 5-point Likert scale. Conclusions Virtual reality using RCDP to teach transvenous pacemaker insertion demonstrated an improvement in task trainer performance. Further investigation into whether this translates into better patient outcomes or can be generalized to other procedures needs to be considered.
View details for DOI 10.7759/cureus.18503
View details for PubMedID 34754663
View details for PubMedCentralID PMC8569655
Using a Simulated Model and Mastery Learning Approach to Teach the Ultrasound-guided Serratus Anterior Plane Block to Emergency Medicine Residents: A Pilot Study.
AEM education and training
2021; 5 (3): e10525
Background: The serratus anterior plane block (SAPB) is a safe, single-injection alternative for pain control in patients with rib fractures. This pilot study aims to teach the ultrasound-guided SAPB to emergency medicine (EM) residents using a mastery learning approach.Methods: A 19-item checklist was created and mastery was determined to be 17 of 19 items correct. This pass score was established using a Mastery Angoff standard-setting exercise with a group of EM experts. Learners participated in baseline testing on a simulated model and performance was assessed by two raters. Learners then watched an instructional video and participated in an individualized teaching session. Learners underwent deliberate practice followed by posttesting until mastery was achieved. Score differences in baseline testing and posttesting were analyzed using a paired t-test. Pre- and posttesting surveys were also completed by participants.Results: Twenty-eight PGY-1 to -4 residents volunteered to participate in the study. The range of reported SAPBs seen previously was 0 to 5. The mean (±SD) number of items correct on the checklist for initial testing was 8.5 of 19 (±2.7), while the mean (±SD) final score was 18 of 19 (±0.6; p<0.001). All participants met mastery standards after the curriculum intervention. Median self-reported procedural confidence was 2 out of 5 on a 5-point Likert scale before the session and 5 out of 5 after the session (Z=-4.681, p<0.001).Conclusions: Using a mastery learning approach and simulated model, we were able to successfully train EM residents to perform the SAPB at a level of mastery and increase their overall confidence in executing this procedure.
View details for DOI 10.1002/aet2.10525
View details for PubMedID 34041432
Mastery learning improves simulated central venous catheter insertion by emergency medicine teaching faculty
Academic Emergency Medicine Education & Training
View details for DOI 10.1002/aet2.10703
Using In Situ Simulations to Improve Pediatric Patient Safety in Emergency Departments.
Academic medicine : journal of the Association of American Medical Colleges
PROBLEM: Given the complex interaction between patients, individual providers, health care teams, and the clinical environment, patient safety events with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments (EDs). With low-frequency, high-risk events such as pediatric resuscitations, health care teams working in EDs may not have the clinical opportunity to identify deficiencies, review and reinforce knowledge and skills, and problem solve in authentic clinical conditions. Without creating opportunities to safely practice, hospitals run the risk of having health care teams and environments that are not prepared to provide optimal patient care.APPROACH: Researchers employed a case series design and used a train-the-trainer model for in situ simulation. They trained health care professionals (instructors) in 3 general, non-academic EDs in the San Francisco Bay area of California to perform pediatric resuscitation in situ simulations in 2018-2019. In situ simulations occur in the clinical work environment with simulation participants (teams) who are health care professionals taking care of actual patients.OUTCOMES: Teams made up of physicians, nurses, and ED technicians were evaluated for clinical performance, teamwork, and communication during in situ simulations conducted by instructors at baseline, 6 months, and 12 months. Debriefing after the simulations identified multiple latent safety threats (i.e., unidentified potential safety hazards) that were previously unknown. Each ED's pediatric readiness-their ability to provide emergency care for children-was evaluated at baseline and 12 months.NEXT STEPS: The authors will continue to monitor and examine the impact and sustainability of the pediatric in situ simulation program on pediatric readiness scores and its possible translation to other high-risk clinical settings, as well as explore the relationship between in situ simulations and patient outcomes.
View details for DOI 10.1097/ACM.0000000000003807
View details for PubMedID 33116057
Applying Educational Theory and Best Practices to Solve Common Challenges of Simulation-based Procedural Training in Emergency Medicine.
AEM education and training
2020; 4 (Suppl 1): S22–S39
Objectives: Procedural competency is an essential prerequisite for the independent practice of emergency medicine. Multiple studies demonstrate that simulation-based procedural training (SBPT) is an effective method for acquiring and maintaining procedural competency and preferred over traditional paradigms ("see one, do one, teach one"). Although newer paradigms informing SBPT have emerged, educators often face circumstances that challenge and undermine their implementation.The goal of this paper is to identify and report on best practices and theory-supported solutions to some of these challenges as derived using a process of expert consensus building and reviews of the existing literature on SBPT.Methods: The Society for Academic Emergency Medicine (SAEM) Simulation Academy SBPT Workgroup convened approximately 8 months prior to the 2019 SAEM Annual Meeting to perform a review of the literature and participate in a consensus-building process to identify solutions (in the form of best practices and educational theory) to these challenges faced by educators engaging in SBPT.Results and Analysis: Thirteen distinct educational challenges to SBPT emerged from the expert group's primary literature reviews and consensus-building processes. Three domains emerged upon further analysis of the 13 challenges: learner, educator, and curriculum. Six challenges within the "learner" domain were selected for comprehensive discussion in this paper, as they were deemed representative of the most common and most significant threats to ideal SBPT. Each of the six challenges aligns with one of the following themes: 1) maximizing active learning, 2) maintaining learner engagement, 3) embracing learner diversity, 4) optimizing cognitive load, 5) promoting mindfulness and reflection, and 6) emphasizing deliberate practice for mastery learning. Over 20 "special treatments" for mitigating the impact of the 13 challenges were derived from the secondary literature search and consensus-building process prior to and during the preconference workshop; 11 of these that best address the six learner-centered challenges are explored, including implications for educators involved in SBPT.Conclusions/Implications for Educators: We propose multiple consensus-generated solutions (in the form of best practices and applied educational theory) that we believe are suitable and well aligned to overcome commonly encountered learner-centered challenges and threats to optimal SBPT.
View details for DOI 10.1002/aet2.10418
View details for PubMedID 32072105
Mastery Learning Ensures Correct Personal Protective Equipment Use in Simulated Clinical Encounters of COVID-19.
The western journal of emergency medicine
2020; 21 (5): 1089–94
The correct use of personal protective equipment (PPE) limits transmission of serious communicable diseases to healthcare workers, which is critically important in the era of coronavirus disease 2019 (COVID-19). However, prior studies illustrated that healthcare workers frequently err during application and removal of PPE. The goal of this study was to determine whether a simulation-based, mastery learning intervention with deliberate practice improves correct use of PPE by physicians during a simulated clinical encounter with a COVID-19 patient.This was a pretest-posttest study performed in the emergency department at a large, academic tertiary care hospital between March 31-April 8, 2020. A total of 117 subjects participated, including 56 faculty members and 61 resident physicians. Prior to the intervention, all participants received institution-mandated education on PPE use via an online video and supplemental materials. Participants completed a pretest skills assessment using a 21-item checklist of steps to correctly don and doff PPE. Participants were expected to meet a minimum passing score (MPS) of 100%, determined by an expert panel using the Mastery Angoff and Patient Safety standard-setting techniques. Participants that met the MPS on pretest were exempt from the educational intervention. Testing occurred before and after an in-person demonstration of proper donning and doffing techniques and 20 minutes of deliberate practice. The primary outcome was a change in assessment scores of correct PPE use following our educational intervention. Secondary outcomes included differences in performance scores between faculty members and resident physicians, and differences in performance during donning vs doffing sequences.All participants had a mean pretest score of 73.1% (95% confidence interval [CI], 70.9-75.3%). Faculty member and resident pretest scores were similar (75.1% vs 71.3%, p = 0.082). Mean pretest doffing scores were lower than donning scores across all participants (65.8% vs 82.8%, p<0.001). Participant scores increased 26.9% (95% CI of the difference 24.7-29.1%, p<0.001) following our educational intervention resulting in all participants meeting the MPS of 100%.A mastery learning intervention with deliberate practice ensured the correct use of PPE by physician subjects in a simulated clinical encounter of a COVID-19 patient. Further study of translational outcomes is needed.
View details for DOI 10.5811/westjem.2020.6.48132
View details for PubMedID 32970559
- Owning the Trauma Bay: Teaching Trauma Resuscitation to Emergency Medicine Residents and Nurses through In-situ simulation Journal of Education and Teaching in Emergency Medicine 2020; 5 (4)
Improving Emergency Department Airway Preparedness in the Era of COVID-19: An Interprofessional, In Situ Simulation
Journal of Education and Teaching in Emergency Medicine
2020; 5 (3)
View details for DOI 10.21980/J8V06M
- Mastery Learning in Medical Simulation StatPearls Publishing. Treasure Island, FL. 2020 ; StatPearls
- Use of Video During Debriefing in Medical Simulation StatPearls Publishing. Treasure Island, FL. 2020 ; Stat Pearls
- In Situ Debriefing in Medical Simulation StatPearls Publishing. Treasure Island, FL. 2019 ; StatPearls
- Rapid Cycle Deliberate Practice in Medical Simulation StatPearls Publishing. Treasure Island, FL. 2019 ; StatPearls
- Quality Improvement in Medical Simulation StatPearls Publishing. Treasure Island, FL. 2019 ; StatPearls
- Evaluation of Faculty Debriefing Post simulation Events StatPeals Publishing. Treasure Island, FL. 2019 ; StatPearls
Acute Infectious Diarrhea
EMERGENCY MANAGEMENT OF INFECTIOUS DISEASES, 2ND EDITION
View details for Web of Science ID 000562853400027
Disaster Medicine: A Multi-Modality Curriculum Designed and Implemented for Emergency Medicine Residents.
Disaster medicine and public health preparedness
2016; 10 (4): 611-614
Few established curricula are available for teaching disaster medicine. We describe a comprehensive, multi-modality approach focused on simulation to teach disaster medicine to emergency medicine residents in a 3-year curriculum.Residents underwent a 3-year disaster medicine curriculum incorporating a variety of venues, personnel, and roles. The curriculum included classroom lectures, tabletop exercises, virtual reality simulation, high-fidelity simulation, hospital disaster drills, and journal club discussion. All aspects were supervised by specialty emergency medicine faculty and followed a structured debriefing. Residents rated the high-fidelity simulations by using a 10-point Likert scale.Three classes of emergency medicine residents participated in the 3-year training program. Residents found the exercise to be realistic, educational, and relevant to their practice. After participating in the program, residents felt better prepared for future disasters.Given the large scope of impact that disasters potentiate, it is understandably difficult to teach these skills effectively. Training programs can utilize this simulation-based curriculum to better prepare the nation's emergency medicine physicians for future disasters. (Disaster Med Public Health Preparedness. 2016;0:1-4).
View details for DOI 10.1017/dmp.2016.8
View details for PubMedID 27040319