IDEA Series: Escape the 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. 

Equipment

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
• 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

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 docshahan83@hotmail.com.

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. 

References

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.

Author information

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