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 “Snake Room” gamification-based, timed activity teaches and assesses clinical practice essentials in the management of snakebites among EM residents.
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.
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.
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
- 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
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.
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].
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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)
- World Health Organization. Guidelines for the clinical management of snake bites in the South-east Asia region. 2005.
- 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.
Adult learning theory supports medical educators in moving away from long lectures with minimal engagement from the learners . Core emergency medicine (EM) topics lend themselves well to interactive methods such as gamification . Puzzle-based activities can successfully facilitate team building in medical education .
EM residents commonly encounter acute venous thromboembolism (VTE) in the ED and must know the spectrum of presentations and approach to evaluation and treatment, including the use of risk stratification calculators.
- To improve teaching of acute VTE to EM residents, we created a puzzle-based activity called “Acute VTE Escape Room.” Two teams competed against each other to solve the theme case by unlocking clues with mini puzzles, similar to the format of commercial escape rooms.
- As this game comprised part of the intern core curriculum, all participants were interns, with the puzzles targeted to the expected knowledge base of a PGY-1 EM resident.
- Group size was 4-5 learners
- Box with the ability to lock it
- Numerical padlock
- Opaque envelopes
- Laptop or tablet
- Printed clues, questions and theme case components (Fig 1)
- Note: If interested in obtaining printouts used in this activity, please contact Dr. Elspeth Pearce on Twitter (@ElspethKPearce)
Description of the Innovation
Interns were split into 2 groups to compete against each other and race the clock to solve the case within 45 minutes. Two senior residents, one per group, assisted with the question-and-answer portion of the game. The interns had access to smartphones during the activity, and were encouraged to utilize them to access risk stratification tools during the first mini puzzle.
A theme case of obstructive shock secondary to catastrophic thrombosis of an IVC filter  was presented in pieces as the teams unlocked additional components of the case. The teams were given the case stem introducing the patient, chief complaint, and vital signs. They then had to unlock a box using a 4-digit passcode. This first mini puzzle had 3 cases with risk stratification scores that could be deduced. Once they calculated the risk scores they were able to unlock the box and were given the theme case history of present illness, physical exam, and instructions for the next puzzle.
The groups then had to order diagnostic laboratory and imaging tests to further evaluate the patient described in the theme case. Results were made available for tokens, with the cost of the tests similar in scale to what patients might encounter in the ED. This corresponded to an added educational objective to teach residents about resource utilization and cost of care. Labs and ECG cost 1 token and more expensive diagnostics cost 3-5 tokens. The teams earned the tokens by answering written board exam style questions (some sourced from existing board review question banks and others written by the instructor) from volunteer senior residents. Participants received the results of the tests in envelopes after they purchased them with tokens. The envelope for the lower extremity Doppler ultrasound included an additional puzzle necessitating completion in order to obtain the results.
The final mini puzzle included 4 ECGs that could be seen in acute pulmonary embolism with four questions to answer. Participants filled in the answers in boxes. Highlighted boxes yielded a passcode required to access a PowerPoint that then revealed a video of a positive ultrasound for DVT. The interns were expected to interpret this ultrasound, apply this result to the case components they had obtained, and report the final diagnosis and treatment to the instructor. A prize was awarded to the winning team.
Both groups had 45 minutes to complete the activity, allowing the instructor roughly 10 minutes to debrief, answer questions, and deliver a brief lecture on acute VTE. After completion of the activity, the participants filled out a survey evaluating the activity.
This activity was completed in-person during the hour designated for the intern core curriculum prior to the start of the resident didactic conference. Nine out of ten (90%) interns completed the acute VTE escape room and 6 (66.7%) completed the post event survey (Fig 2). Both groups finished in the time allotted with one group requiring help from the instructor to finish on time. All participants agreed or strongly agreed that the time was used effectively, and the material was presented in a clear and organized manner. Five participants (83.3%) strongly agreed that the material was delivered in an enthusiastic and stimulating way. The comments on the activity were overwhelmingly positive: “Fun and engaging way to learn about the topic”, “I LOVED this activity and really enjoyed it! Thanks for organizing it!”
We successfully developed this game for a small group of residents at approximately the same level of medical knowledge. Adjusting the activity to target a more heterogeneous knowledge base would allow for participation by EM residents of all levels. The questions used for obtaining tokens (mini puzzle 2) and the ECG reading (mini puzzle 3) could be adjusted to the level of learner. We would recommend small group sizes as we discovered the printouts were hard to share amongst the whole group. The debrief session at the end provided a key opportunity to address any remaining questions among learners and clarify any ongoing knowledge gaps. Both groups needed some explanation of the theme case given that it involved a rare and difficult diagnosis to make. As both groups answered some of the most difficult board review questions incorrectly, future iterations may seek to better target questions to the level of the learner.
Theory Behind the Innovation
Gamification, as described by Bíró in 2014, was used as the educational theory foundation for this escape room style activity . Each learner working with a team could create their own path to the correct answers. The groups and the competitive environment provided the motivation to quickly learn and adapt to the puzzles presented.
The debrief session at the end allowed us to address existing gaps in medical knowledge and unpack emotions experienced by participants during gameplay. Debriefing theory allows the instructors of an activity, usually simulation, to create an emotionally charged event within a safe space for learning . Through the debrief, instructors can identify and address gaps in clinical knowledge uncovered during gameplay.
Read other IDEA Series innovations.
- Cooper AZ, Richards JB. Lectures for Adult Learners: Breaking Old Habits in Graduate Medical Education. Am J Med. 2017 Mar;130(3):376-381. Epub 2016 Nov 28. PMID: 27908794.
- IDEA Series: Toxicology Virtual Escape Room during COVID-19. Academic Life in Emergency Medicine. Accessed September 22, 2021.
- Zhang XC, Lee H, Rodriguez C, Rudner J, Chan TM, Papanagnou D. Trapped as a Group, Escape as a Team: Applying Gamification to Incorporate Team-building Skills Through an “Escape Room” Experience. Published online 2018. doi:10.7759/cureus.2256
- Pearce EK. An Uncommon Cause of Shock: Acute Thrombosis of the Inferior Vena Cava. J Emerg Med. 2021 Jul;61(1):67-69. Epub 2021 May 8. PMID: 33972133.
- Bíró GI. Didactics 2.0: A Pedagogical Analysis of Gamification Theory from a Comparative Perspective with a Special View to the Components of Learning. Procedia – Soc Behav Sci. 2014;141:148-151. Doi: 10.1016/j.sbspro.2014.05.027
- Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007 Summer;2(2):115-25. PMID: 19088616
In medical training there is a lack of simulation based activities including procedural labs. Suturing is a critical skill for trainees to master in the emergency department. However, supervised practice is needed prior to suturing a real patient for the first time. This innovation allows early trainees to master suturing while on shift, using easy to find materials, which increases procedural competency and confidence. This activity allows the teacher to assess and correct the trainees procedural skills prior to attempting to suture a real patient.
Name of innovation
- This Do-It-Yourself Suture Kit Station incorporates easy to find materials available in every emergency department, allowing early trainees to master suturing prior to suturing real patients.
- Medical students and early trainees who need suture practice
General group size
- One-on-one student training is ideal, but can have multiple students who can practice using multiple suturing stations
- If teacher unable to instruct while on shift, trainees can be shown a suture training video and practice alongside the video
- Blue chuck pad
- Paper/cloth tape
- Suture material
- Suture kit
More detailed description of the activity and how it was run
- Make the DIY Suture Kit Station (see above video):
- Place a thick chuck pad on a flat sturdy surface.
- Apply cloth tape to the entire surface of the chuck, and tape over the chuck. This is now the suturing pad.
- Use a scalpel to make an incision to the pad.
- Use the back blunt end of the scalpel to ‘fluff’ up incision edges to make laceration.
- Use a laceration repair kit and suture to close the laceration.
- Instruct the trainee on proper suturing technique on the suture station (or show a suture training video)
- Have the trainee continue practicing until adequate comfort and proficiency level is achieved
- Suture real patient!
Lessons learned, especially with regard to increasing resident and program buy in
- Procedural skills require much repetition to gain proficiency. This is best done with video tutorials, supervision, and deliberate practice.
- Practicing in a simulated environment greatly improves skill and confidence in real clinical practice.
Educational theory behind the innovation including specifics/styles of teaching involved
- Simulation practice increases procedural competency.
- Practicing on shift allows trainees to reach the number of repetitions required to gain mastery in suturing, Routt  showed that the number of repetitions required to gain proficiency was 41 times.
- Competency in suturing is required even when cases are low. Wongkietachorn et al. demonstrated that tutoring suturing improves the trainees’ skillset. A practice suture kit helps improve retention for real-life scenarios .
- This DIY suture pad station technique is easily available and inexpensive.
- To improve suturing techniques and enhance skill retention, medical students and early trainees need to learn with guided supervision on simulated task trainers.
- Routt E, Mansouri Y, de Moll EH, Bernstein DM, Bernardo SG, Levitt J. Teaching the Simple Suture to Medical Students for Long-term Retention of Skill. JAMA Dermatol. 2015 Jul;151(7):761-5. doi: 10.1001/jamadermatol.2015.118. PMID: 25785695.
- Wongkietkachorn A, Rhunsiri P, Boonyawong P, Lawanprasert A, Tantiphlachiva K. Tutoring Trainees to Suture: An Alternative Method for Learning How to Suture and a Way to Compensate for a Lack of Suturing Cases. J Surg Educ. 2016 May-Jun;73(3):524-8. doi: 10.1016/j.jsurg.2015.12.004. Epub 2016 Feb 20. PMID: 26907573.