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IDEA Series: Toxicology Virtual Escape Room during COVID-19

By Alexis Cates, DO July 15, 2020 0 comments

In order to enhance emergency medicine (EM) residents’ knowledge of toxicology core content, we previously created an immersive escape room experience complete with team-based puzzle solving in a geographical maze to find an antidote. The subsequent COVID-19 pandemic and physical distancing guidelines resulted in canceled in-person EM conferences, thereby requiring a rapid adaptation to virtual formats [1-4]. Our toxicology division sought a novel method of engaging learners with toxicology core content remotely. 

Name of Innovation

We developed a virtual version of a toxicology-themed escape room utilizing Google Forms titled “Escape the Toxin: Online!” In this activity, participants are presented with a case of a patient exhibiting signs and symptoms of a toxidrome. They must subsequently solve multiple intermingled toxicology-related challenges. Those who select the correct mechanism of action for the antidote ultimately “escape the toxin.”

Detailed description of the activity

The activity was introduced during the infancy of virtual weekly didactics conferences at our institution and was thus made optional for participation as a trial. Residents were randomly assigned into breakout rooms utilizing Zoom video conferencing software. After a brief introduction, participants received a Google Forms link directing them to the game (See Figure 1).  Each team was allotted 45 minutes to complete the challenge.

Figure 1: This screenshot of a Google Form demonstrates the opening rhyme and instructions that introduces participants to the game. The curriculum is available to be shared upon request to the author.

The virtual “room,” a Google form, opens with a fun, rhyme-filled introduction and a light-hearted question to immerse all participants into the game. The groups that have been separated into breakout rooms via Zoom act as a team but individually were required to fill out the Google form, partially to prove attendance for conference hours credit and partially to ensure participation. To move forward through the Google form, participants were required to answer all of the questions. In order to preserve flow, the answers did not have to be correct to move to the next puzzle, and participants were not notified in real time if their answer was incorrect. However, in order to accomplish the ultimate goal of picking the correct antidote (located in the final puzzle), the participant needed to have identified the toxidrome that was described in the initial description of the case. The remaining questions and puzzles that follow all have rhyming stems to apply gamification mechanics which mimic the in-person escape room experience. A variety of answer choices were utilized, including anagrams, fill-in-the-blank, multiple choice or short answer (See Figure 2).

Figure 2: This screenshot of a Google Form demonstrates an example of one of the questions participants must answer in order to move on to the next puzzle.

The puzzles were intended to be challenging and thought-provoking, especially since rhyming mechanics were used. Much like an in-person escape room, brainstorming, thinking out loud and teamwork were required to decipher the intent of the rhyme. However, the puzzles always referenced the toxidrome and antidote pair, including signs, symptoms, diagnostic findings, alternative therapies and additional treatments by the antidote. The final question inquired about the mechanism of action of the proposed antidote (that matched with the original poisoning causing the case presented toxidrome).

During the challenge in their Zoom breakout rooms, learners were allowed to use any available resources to answer their questions. They were encouraged to text, chat, or email the facilitator if they had questions. They were allowed to discuss amongst each other in their breakout rooms and look to other open resources for clues. We intended to replicate the same teamwork necessary to solve the puzzles as required in an in-person escape room activity.

At the end of the activity, a short 3-question survey was embedded in order to obtain feedback about learner’s attitude toward this mechanism for learning toxicology content, the appropriateness of the amount of time allotted, and whether the participant would recommend the activity to other EM residents. Responses were required to these likert-scale questions to complete the game. After the live session, participants were invited to debrief about the puzzles and the case. The responses to the individual Google Forms were reviewed. The top learners were identified and considered to have “escaped the toxin” if they met the following criteria:   they selected the correct mechanism of action of the antidote, they had the most correct answers from the puzzles, and they completed the activity within the allotted 45 minutes.


The activity was made optional as part of weekly residency didactics. There were 17 participants out of a residency program of 60 individuals. The participants all completed the activity in the time allotted, and 88% (15 out of 17) completed the task by identifying the correct mechanism of action of the antidote. Ninety-four percent found the activity helpful or very helpful as a teaching tool for stimulating the study of toxicologic concepts and 100% agreed or strongly agreed that they would recommend this activity to other EM residents.


  • Participation: This session was scheduled for the last hour of the weekly EM residency conference, which can be challenging for those residents scheduled to work clinical shifts immediately after to attend. It was also offered as an optional activity as it occurred in the very early phases of virtual conference. Both of these factors may have negatively impacted attendance. In order to increase participation in the future, we anticipate making this a required activity scheduled earlier in the conference day and/or providing it as an asynchronous opportunity.
  • Technology: Technology failures are common for virtual educational activities and necessitate back-up plans. When the Zoom meeting spontaneously cut out and the participants needed to be reassigned to breakout rooms, they were randomly sorted into new groups with new team members. In the future, we plan to manually assign participants into groups in advance so that we can quickly place them back into the same teams in the event of a technology failure. Tracking each individual group’s time limit and providing educational and technological support to multiple groups was also challenging. In the future, we plan to assign a facilitator to each small group to assist with these activities.

Theory behind the innovation

Based loosely on the model described by Drs. Garrison, Anderson and Archer, this innovation incorporates game mechanics to create a community of inquiry [5]. Three components contribute to the educational activity: social presence (small groups actively working together), cognitive presence (group and personal intrigue triggered by the puzzle, worked through until resolution), and finally teaching presence (facilitators with pre- and post-activity discourse specific to the educational objectives).


  1. Frequently Asked Questions. (n.d.). Retrieved from ACGME website:; April 28, 2020.
  2. Virtual Learning Resources. (n.d.). Retrieved from Council of Residency Directors in Emergency Medicine website:–curricula/virtual-learning-resources/; April 28, 2020.
  3. Online CME and Learning Resources for DOs and Osteopathic Medical Students. (March 24, 2020). Retrieved from the DO online newsletter.; April 28, 2020.
  4. Gottlieb M, Landry A, Egan DJ et al. Rethinking Residency Conference in the Era of COVID-19. AEM Education and Training 2020;00;1-5.
  5. Garrison, Anderson and Archer. “Community of Inquiry Model”,  Accessed April 30, 2020.







Author information

Alexis Cates, DO

Alexis Cates, DO

Medical Toxicology Fellow
Department of Emergency Medicine
Albert Einstein Healthcare Network

Philadelphia, PA

The post IDEA Series: Toxicology Virtual Escape Room during COVID-19 appeared first on ALiEM.

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