My Broken Heart.

Audience: The target audience for the key learning objectives of this Left-Ventricular Assist Device (LVAD) simulation are emergency medicine residents. Other team members such as attendings, nurses, pharmacists, and technicians could potentially be integrated.

Introduction: Left ventricular assist devices (LVADs) are common bridge therapy for patients suffering from severe heart failure to cardiac transplant or destination therapy for non-transplant candidates.1 Emergency medicine physicians must be prepared for a variety of device complications that may result in an acute care presentation, such as drive-line infections, suction events, arrhythmias, and cardiac arrest with device failure. In a review investigating ED presentations for patients with LVADs, device-specific complaints were among the fewest, with the most common presentations involving bleeding, infection, and arrythmias.2 The present case involves a suction event that is precipitated by a gastrointestinal (GI) bleed, which has an incidence of 30% for LVAD patients.3 This case was developed for a technology failure-themed resident simulation competition during the Western Society for Academic Emergency Medicine (SEAM) conference held on April 1, 2022.

Educational objectives: By the end of this simulation session, learners will be able to: 1) assess the hemodynamics of an LVAD patient by using a Doppler to determine mean arterial pressure, 2) Manage an arrhythmia in an LVAD patient with a suction event by addressing preload, 3) Identify and treat the source of hypovolemia (a massive lower gastrointestinal hemorrhage), 4) Perform clear closed-loop communication with other team members.

Educational methods: This high-fidelity simulation case aims to train emergency medicine residents on recognition and management of an LVAD suction event, a rare but serious presentation encountered in the emergency department. This simulation can be successfully implemented either in situ, in an immersive simulation center, or off-site. This case could be represented by lower fidelity mannequins without the capabilities to provide learner tactile feedback of hemodynamics or airway, with a separate monitor device such as SimMon to display vital signs and digital media to demonstrate needed clinical images. The audio file of the low-flow alarm can be accessed and played by any device with internet access. The simulation benefits from embedded simulation participants to act as the bedside nurse and wife to provide history. This simulation included debriefing focused on a critical action checklist.

Research methods: A working group of two simulation-trained faculty, a simulation fellow, and three senior emergency medicine residents chose and developed the simulation case. Two simulation-trained faculty implemented the pilot case series to gather feedback on performance against the critical action checklist. One simulation-trained faculty then facilitated two additional in situ sessions, again evaluating performance on the critical actions as well as content of the debrief discussion. That data was used to iteratively edit the presentation and dynamics of the case in preparation for the SIMposium case competition.

Results: During March 2022, in a three-case pilot in situ series, a total of 15 residents (five EM PGY4, four EM PGY3, five EM PGY2, one off-service PGY1) and two medical students (MS3) participated in the simulation case. Participant reactions were overwhelmingly positive, particularly from senior residents. The final version of the SIMposium case was held for a team of four emergency medicine residents from an alternate institution, all critical actions were met, and a discussion point arose regarding the reversal of anticoagulation in LVAD patients with acute GI bleed.

Discussion: Overall, this simulation was well received, effective, and easy to implement and translate to immersive, in situ, or offsite locations for the training of emergency medicine residents on the management of a high acuity, low-frequency event of LVAD device complication. Each debrief stimulated an excellent discussion regarding the general management of LVAD patients regarding initial assessment, arrhythmia, and distinguishing pathologies from device alarms. Our main takeaway from this simulation was the power of a case involving a critical and high acuity patient with LVAD which stimulated residents to engage in more robust discussions during debriefing, leading to broader clinical learning.

Topics: In situ simulation, simulation competition, LVAD, left ventricular assist device.