High Altitude Pulmonary Edema

AUDIENCE: This simulation was developed to educate emergency medicine residents on the diagnosis and management of high-altitude pulmonary edema (HAPE). This case is also appropriate for senior medical students and advanced practice providers. The principles of crisis resource management, teamwork, and communication are incorporated into the case. INTRODUCTION: High altitude pulmonary edema may present similarly to pneumonia with nonspecific symptoms, including decreased exercise tolerance, cough, dyspnea with exertion, and fever. Symptoms more specific to HAPE include dyspnea at rest, tachypnea, history of rapid ascent to high altitude, a lowlander patient exposed to high-altitude, or a highlander patient on re-entrance to high altitude after lowland stay. Laboratory and imaging workup may include infiltrates on chest x-ray and leukocytosis.1,2 Of the various forms of altitude sickness, HAPE has the highest fatality rate, estimated at 50% in travellers to the Himalayas who are unable to descend.1 Providers should inquire as to the current elevation of their facility, the patient’s recent altitude gain, and the rate of ascent. Treatment priorities include oxygen and immediate descent, as well as supplemental treatment with nifedipine and phosphodiesterase (PDE) inhibitors such as sildenafil or tadalafil. EDUCATIONAL OBJECTIVES: At the conclusion of the simulation session, learners will be able to: 1. obtain a thorough history relevant to altitude illnesses; 2. develop a differential for dyspnea in a patient with environmental exposures; 3. discuss prophylaxis and management of HAPE; 4. discuss appropriate disposition of the patient including descent and subsequent appropriate level of care. EDUCATIONAL METHODS: This session was conducted using high-fidelity simulation followed by a debriefing session and lecture on the diagnosis and management of HAPE. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This technique includes an observation statement, a statement describing the framework of the observer, and an invitation to review further to explore the participants’ frames. An example of this advocacy-inquiry is as follows: “I heard Sam suggest to the team that acetazolamide be given, but then I didn’t hear any follow-up discussion. Acetazolamide is often utilized for acute mountain illness prophylaxis or treatment. I wasn’t sure if the team did not hear his suggestion or disagreed with the treatment plan. Tell me more.” This scenario was designed as a simulation, but it could be adapted as an oral boards case. RESEARCH METHODS: Our residents were provided with a survey at the completion of the simulation and debriefing to rate different aspects of the simulation, as well as to provide qualitative feedback. RESULTS: Participants expressed positive feedback, with comments focused on appreciating the review of the presentation, diagnosis, and treatment of altitude illness. The emergency medicine residents surveyed currently practice in a low altitude setting and were appreciative to simulate a scenario to which they might otherwise not get exposure during their residency. Our simulation center’s feedback form is based on the Center of Medical Simulation’s Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form. This session received all 6 or 7 scores (consistently effective/very good or extremely effective/outstanding) other than a 5 for setting the stage, a 4 for maintaining an engaging context for learning, and two 5s for structured debriefing. DISCUSSION: This was an effective method to review high altitude illness with learners that may otherwise get limited exposure to such clinical cases during residency. Learners had a broad range of differential diagnoses and demonstrated variable levels of knowledge related to the diagnosis and treatment of high-altitude illness. We used visual stimuli and a reminder from our nurse to reinforce for the learners that the case was taking place at a critical access emergency room at 11,000 feet of elevation. TOPICS: Medical simulation, high altitude pulmonary edema, high altitude cerebral edema, altitude sickness, emergency medicine, wilderness medicine.