Emergency Department Presentation of a Patient with Altered Mental Status: A Simulation Case for Training Residents and Clinical Clerks.

Emergency physicians frequently are required to perform timely assessments on patients who are unable to provide a comprehensive history due to an altered level of responsiveness. The etiology of their altered mental status (AMS) causes a diagnostic dilemma due to its wide differential diagnosis. Physicians must use a timely combination of collateral history, physical examination skills, and investigations to diagnose the cause of the patient's AMS, as many of the potential etiologies can be life-threatening if not quickly managed. For this reason, training learners to perform the required actions accurately and effectively proves difficult during real-life emergencies, where an individual's life may be at risk. Simulation-based education (SBE) offers one solution to this challenge. It allows learners to build confidence by dealing with life-threatening conditions in a safe environment and has been shown to be superior to other forms of clinical training.  This scenario explores learners' comfort in some less-practiced, but very important, areas of medicine including obtaining consent for treatment from a substitute decision maker (SDM), explaining various goals of care, and eliciting an advanced care directive from the SDM. Learners and physicians in all fields of medicine must be able to confidently discuss these subjects with patients and their families in order to provide individualized and appropriate management. In this simulation, learners will have the opportunity to explore an unusual AMS presentation and develop their clinical and communication skills by working as a team to manage the patient.