About Shahan Waheed, MBBS, MD, FCPS

Assistant Professor, Department of Emergency Medicine
Program Director, EM Residency Program
Aga Khan University Hospital (AKUH)
Karachi, Pakistan

Trick of Trade: Removal of Entrapped Metal Zipper

zipper entrapment injury

A young boy is brought to the pediatric emergency screaming at the top of his lungs by his parents. His penile skin is trapped in the zipper of his jeans. On a busy shift, you want a simple way to handle zipper injuries that minimizes pain, doesn’t require resource-intensive procedural sedation, and is quick.


The 4 most common types of zippers are nylon coil zip, plastic mold zip, metal zip, and invisible zip. Most of the techniques describing solutions on zipper entrapment in the medical literature are derived from case reports and case series. All revolve around understanding zipper anatomy and obtaining adequate exposure to assess how the skin is entrapped. The penile skin often is entrapped either in the sliding mechanism (also known as the endplate) or between the teeth of the zipper.

zipper anatomy

Figure 1. Anatomy of a zipper

Penile Entrapment Injury Management Techniques in Literature

Reported techniques for releasing zippers include [1, 2]:

  • Cut the sliding mechanism (aka the endplate) using metal cutters.
  • Use a flat screwdriver placed underneath the sliding mechanism and rotate it.
  • Use mineral oil for lubrication.
  • Use lateral compression technique to relieve the tension on the trapped skin.
  • Cut the zipper and pull the teeth apart.

All these techniques are associated with variable rates of success. Some of these techniques such as using metal cutters might lead to iatrogenic injuries.

The problem is that the child’s penile skin is entrapped within a metal zipper, where many recommended methods for zipper entrapment removal won’t work.

Trick of the Trade: Removing Metal Zippers

Materials Needed

  • Lidocaine gel
  • Blade or scissors


  1. The zipper should be separated from the pants as much as possible to minimize painful stretching or pulling of the penile skin.
  2. Apply lidocaine gel on the area of entrapment for 2-3 minutes.
  3. Identify the exposed teeth closest to slider and cut off the zipper at that level (blue dots) while avoiding penile skin (Figure 2).
  4. Gently advance the zipper body forward, pulling either the tab or the body itself, to disengage it from the teeth. You may need to add more lidocaine gel or other lubrication to facilitate this sliding motion.
  5. The remaining parts of the zipper can easily be disengaged from the skin (Figure 3).

metal zipper cut trick zipper entrapment

Figure 2. Cutting off the zipper between the teeth (blue dots) and advancing the zipper body (yellow arrow)

metal zipper entrapped free

Figure 3. Freed zipper body

Interested in Other Tricks of the Trade?


  1. Leslie SW, Sajjad H, Taylor RS. Penile Zipper and Ring Injuries. [Updated 2023 Mar 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
  2. Tasian GE, Belfer RA. Genitourinary trauma. In: Fleisher and Ludwig’s Textbook of Pediatric Emergency Medicine, 7th ed, Shaw K, Bachur RG (Eds), Lippincott Williams & Wilkins, Philadelphia 2015.

IDEA Series: LUDO game to teach residents about urogenital diseases

The Problem: Urogenital diseases are commonly encountered in the emergency department [1]. Both the WHO and CDC recommend early identification and timely management of such diseases, to prevent morbidity and mortality [2, 3]. Additionally, the sensitive nature of this topic as well as cultural factors can limit the exposure and bedside teaching by emergency physicians (EPs). Novel learning methods are needed to prepare EPs to manage urogenital diseases effectively and efficiently.

The Innovation

The Learning Urogenital Diseases in Oddity (LUDO) gamification-based, timed activity teaches and assesses clinical practice essentials in the management of urogenital diseases among emergency medicine (EM) residents. This acronym plays off of the age-old game enjoyed across generations in Pakistan, also called Ludo. Adopting this popular game format with EM education enhances learning, facilitating the quick digestion of factoids [4]. The format is simple, adaptable, and can be used to teach topics in an engaging way to any learner group.

The Learners

Emergency medicine residents of all class years

IDEA LUDO game team color hats

Figure 1: LUDO game with team colors, designated by hats. Team red is listening to the question on data interpretation.

Group Size

LUDO requires a total of 3 facilitators for 4 teams, each marked with colors as per the LUDO board (green, red, blue, and yellow).

The 3 facilitator roles:

  1. One handles the laptop
  2. One marks the number of times each group has sought additional resources (limited to 5) on the whiteboard
  3. One serves as an assessor, who monitors the group whose turn it is in the game, as the throw the dice and move their color piece once they answer the question correctly.


Figure 2: Traditional Ludo board with desk bell

Our activity utilizes simple, cheap, and readily available materials, including the following:

  • LUDO board: A square-shaped, strategy board game for 2-4 players [Ludo game on Amazon] with a pattern on it in the shape of a cross. In this game, the players race their tokens from start to finish according to the rolls of a single die.
  • LED stopwatch: An LED stopwatch was placed on the side of the projector screen. A 1-minute timer was started after the question was read to the team by the facilitator at the laptop and was reset before the next team’s turn.
  • Laptop and projector: A laptop and projector were utilized to display PowerPoint slides as a part of the activity. For example, participants had to view images, true/false questions, multiple choice questions, fill-in-the-blank questions, and rapid-fire questions on the slides. These questions prompted them to identify different aspects of urogenital diseases, as well as differentiate images of genital ulcers that patients may present at urgent care clinics or emergency departments.
  • Colored caps: Four different colored hats, matching the game pieces, were distributed to each person to designate which team they were on.
  • Desk bell: A desk bell could be rung by the team member in the “hot seat” if they wanted to answer the question differently from their team’s consensus answer.

Description of the Innovation

LUDO is a strategy board game for 2-4 players, in which teams race their 4 tokens from start to finish according to single-die rolls. A video description of the traditional Ludo game rules is below. This IDEA innovation mirrored these rules with slight modifications and took place over a 2-hour period.

Before the start of the activity, the activity director provided an introduction regarding the rules and regulations of the program that were also shared through email and WhatsApp a week before the activity.

In our LUDO variation, we assigned 4 team captains to take the “hot seats”, who were responsible for rolling the dice and had the final say in answering their team’s questions. To begin moving their tokens out of the home base circle, they must roll a 6, as in the actual game. After this, they can only move forward if they can answer the pre-prepared questions assigned to each side of the die. If they cannot answer the question, they stay where they are, and the turn proceeds to the next team. For each question, the captain has a minute to answer the question after consulting their team. An LED digital clock adjacent to the projector screen allows all participants to see the remaining time. If the captain desires to answer the question differently than the team’s consensus answer, he or she must ring the desk bell and then provide the alternative answer.

IDEA series LUDO game token movement

Figure 3: Ludo game token path – this example shows movement of the blue token

‘Getting their token home’ is the main objective of the game, but that is only part of the final evaluation to decide who is the winner. Other vital skills the assessor observes include teamwork, time management, the use of outside resources (i.e., books or the internet), and strategy. For example, there may be times when it is advantageous to answer a question wrong to increase one’s chances of landing on the other team’s token. This would send the other team’s token back to their starting position and force them to restart their travels around the board!

Each team has an option to seek additional resources to answer the question including use of our core textbook of emergency medicine or utilizing their mobile phones to access internet resources. Outside resource usage is limited 5 times per team, as tracked by a facilitator.

idea series LUDO team strategy

Figure 4: Yellow team captain joyfully removing a red team’s token piece after answer the question correctly

During the activity, the assessor facilitator judged each team’s performance through a questionnaire with Likert scales measuring the following:

  1. Knowledge of urogenital diseases
  2. Leadership skills of the team captain
  3. Problem-solving
  4. Communication among the team members
  5. Time management

At the end of the activity, each team completed an evaluation form to provide feedback about the activity to the organizers. Participants were also given timely feedback by facilitators immediately following the activity during a debriefing session, where the activity director identified gaps in knowledge and skills and provided suggestions for how to translate lessons learned to future clinical practice.

Downloadable forms:

Lessons Learned

  • The activity allowed the faculty to assess core EM skills in addition to medical knowledge, such as communication, collaboration, leadership, and problem solving. EM residents also practiced navigating team dynamics and working in a group within a safe learning space promoting collegiality among junior and senior residents.
  • The activity utilizes a popular game as a mode of introducing engagement and interest among residents and facilitates learning on a topic that does not tend to generate significant interest on its own.
  • 360-feedback was obtained:
    1. Faculty assessed learning outcomes via a Likert scale for resident feedback.
    2. Residents participated in mini-interviews at completion of the activity for educator feedback.
    3. The LUDO game’s activity and learning outcomes were assessed through a questionnaire, which was piloted prior to use during the game. The validation of the assessment tool is in process. The assessment form is available upon request by contacting Dr. Shahan.
  • The LUDO activity was well received by the EM residents, who requested to repeat the same format for other modules as well. Participants shared their feedback that this activity offers them a unique educational experience with a team-based approach.
  • Game dynamics can be altered by adjusting the complexity of the case and related questions, but any adjustments should align with the intended learning outcome. To conform to the principles of gamification, it is important that the core principles of the game should not be altered much.

Theory behind the innovation

This activity incorporated gamification and competition-based learning theory to create a positive, impactful educational experience for learners. Teaming participants in small groups facilitates collaboration and development of new knowledge through a social constructivist approach.


Figure 5: Happy faces at the completion of LUDO (left) and the winning group – Team Green (right)


By |2022-12-04T19:19:15-08:00Dec 9, 2022|IDEA series|

IDEA Series: Escape the Snake Room

IDEA series snake room

The Problem

A snakebite from a venomous snake can result in a potentially life-threatening toxin-mediated disease (1). The WHO considers snakebites to be an important occupational disease in Southeast Asia (2). Particularly in rural areas of Pakistan, snakebites represent a common public health concern. The relatively rare nature of this condition in urban environments, however, limits exposure to it by emergency medicine (EM) residents. Thus, additional focused training is necessary to prepare EM physicians to manage snakebites in a timely and effective manner. 

The Innovation

The “Snake Room” gamification-based, timed activity teaches and assesses clinical practice essentials in the management of snakebites among EM residents. 

The Learners

The target learners were EM residents of all class years, although a similar instructional model could be applied for teaching other uncommon diseases in under-resourced settings to any relevant learner group.

Group Size

Snake Room requires 4 total facilitators (1 facilitator per station for 4 stations). Each facilitator supervises 5-7 participants in each group during the time they attempt the station, for a total of up to 28 participants and 4 facilitators. 


This activity utilizes simple and readily available materials, including the following:

  • WHO manual of snakebite management (3): The manual is a comprehensive guide for snakebite management specifically in Southeast Asia. The manual provides management strategies for low-resource settings of relevance to rural areas of our country. The stations were therefore developed in accordance with this reference.
  • Online stopwatch: An online stopwatch was projected on a large screen. A 15-minute timer was started at the beginning of the activity for each group, and was reset before the entry of the next group. 
  • Laptops and speakers: In 2 of the sub-stations, a computer was utilized to display PowerPoint slides as a part of the activity. For example, participants had to view images on the slides and rapidly identify different grades of snake bites, as well as differentiate images of venomous snake bites from other bites (i.e., rodent bites) that patients may present in rural areas. The slides automatically cycled after every 30 seconds. The speakers played snake charmer music in order to create an auditory distraction for the participants to mimic the distracting environment of the ED. 
  • Materials for low-fidelity wound simulation
    • Red slime to mimic features of myonecrosis 
    • Clear occlusive dressings to hold the red slime in place
    • Red, orange, and yellow dry pastel to demarcate inflammation around the bite wound
    • Manikin to demonstrate the bite marks on the lower limb

Description of the Innovation

The “Snake Room” activity took place over a 3-hour period. Four groups consisting of 5-7 members participated. There were 4 stations with 4-5 sub-stations in each station. Each station incorporated gamification and competitive-learning methodology. The substations featured clinical cases, image identification, puzzles, finding the right answer card hidden in the room, and/or low-fidelity wound simulation.

Each group of participants included residents from each class year in order to mimic the team composition most commonly encountered in our clinical environment, where senior level residents supervise a team of junior residents. The activity organizers intentionally formed teams with uniformity in academic and clinical skills to create a level playing field.

Before the start of each station, facilitators also provided a briefing to the group of participants regarding the task and amount of time available to complete it. A projector displayed the time. Groups had 15 minutes to complete each station, and each group attended the stations in the sequential order. Group members had the option to utilize online and/or in-print resources in addition to recall to complete the tasks. 

Effective use of technology was assessed. One of the groups used the Google scan app to identify the key word and obtain the answer to the puzzle.

During the activity, the course director and facilitators actively assessed participant performance as they attempted to work through the stations utilizing a questionnaire with Likert scales measuring the following:

  • Knowledge of snakebite management
  • Problem-solving
  • Leadership skills
  • Communication among team members
  • Allocation of roles among team members
  • Utilization of technology (i.e., mobile devices)
  • Understanding of the task
  • Ability to finish the activity on time
IDEA series snake room completed tasks
Successful completion of the tasks and escape from the Snake Room

The group that completed all of the puzzles and stations successfully in the allotted amount of time and achieved the highest score on the assessments of leadership, task delegation, and communication skills won the competition. 

IDEA Snake Room debrief
Debriefing session with one of the groups

At the conclusion of the activity, participants completed an evaluation form to provide feedback about the activity to the faculty organizers. Participants also received feedback during a debrief session, where faculty identified gaps in knowledge and skills and provided suggestions for how to translate lessons learned to future clinical performance. Later that day, the winning group was announced and each group’s feedback was shared in a single email to all participants, allowing groups to compare their performance. 

Materials for the activity are available upon request by contacting Dr. Shahan at [email protected].

Lessons Learned

  1. The activity allowed faculty to assess core EM skills apart from medical knowledge, such as leadership and communication. EM residents had the opportunity to practice navigating team dynamics, and working in a group within a safe learning environment facilitated collegiality among junior and senior residents.
  2. The faculty who planned the activity sought feedback from participants to optimize future iterations through short-mini interviews with group participants at the end of the activity.
  3. The assessment questionnaire was developed according to local considerations and may warrant adjustment depending on the institution and location in which the activity occurs. Internal and external validation of the assessment tool is in process. 
  4. Substations require careful, intentional planning such that they focus on an isolated aspect of the main theme, such as presentation of the disease or diagnostic test interpretation. 
  5. We incorporated audio distractions to mimic the challenges inherent to the ED environment, where residents must commonly navigate complex clinical scenarios as a team amidst frequent interruptions and competing demands. Visual distractions could also be incorporated. 
  6. Simulations (low- or high-fidelity) can be introduced while planning these sessions, but it should align with the intended learning outcomes and must be appropriately timed to maintain gamification principles. 
  7. The Snake Room activity was well received by EM residents, who requested additional iterations of this activity adapted to other topics. Participants shared their general impression that this activity offers a fun, unique educational experience with a team-based approach. 

Theory behind the innovation

We successfully combined competitive-learning theory with gamification in the Snake Room didactic to result in a positive, impactful educational experience for learners (4). Teaming participants in small groups encouraged collaboration and co-construction of new knowledge in a social constructivist approach. 

Interested in reading more innovations in education?

Read other Ideas in Didactics and Educational Activities (IDEA) series posts on ALiEM.


  1. Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F. Snake bite in South Asia: a review. PLoS neglected tropical diseases. 2010;4(1):e603. PMID: 20126271
  2. Warrell DA. Guidelines for the management of snake-bites. Guidelines for the management of snake-bites. 2010. (https://apps.who.int/iris/handle/10665/204464
  3. World Health Organization. Guidelines for the clinical management of snake bites in the South-east Asia region. 2005.
  4. Robson K, Plangger K, Kietzmann JH, McCarthy I, Pitt L. Is it all a game? Understanding the principles of gamification. Business horizons. 2015;58(4):411-20.

IDEA series: REDman simulation for teaching resuscitation skills in low-resource settings

REDman simulationIn many parts of the world, emergency medicine is just beginning to emerge as a specialty. In Pakistan, for example, it was introduced as recently as 2012. Hands-on training in the management of critically-ill medical and trauma patients is imperative for adequate preparation of board-certified emergency physicians, but accurate simulation can be hard to come by in developing nations. There are very few training programs and dedicated centers for healthcare professionals, and even fewer that have simulation [1]. High-tech simulation equipment is often cost-prohibitive; a mobile, low-tech simulation lab could potentially address the need for advanced training in resuscitation for emergency physicians training in under-resourced hospitals.


By |2020-02-14T09:40:38-08:00Feb 21, 2020|IDEA series, Simulation|
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