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Rustic synonyms
Part of speech:
A piece of literature dealing, usually in an idealized way, with rural life; formerly, specif., a poem, play, etc. treating the rustic lives and loves of shepherds in a conventionalized, artificial manner
A member of the lowly social class which toils on the land, constituted by small farmers and tenants, sharecroppers, farmhands and other laborers on the land where they form the main labor force in agriculture and horticulture.
Of or pertaining to agriculture; connected with, or engaged in, tillage; as, the agricultural class; agricultural implements, wages, et cetera.
The definition of coarse is something that has large particles, poor quality, a rough texture or something that is in bad taste.
sophisticated (antonym)
The definition of sophisticated is someone that is intelligently worldly and smart or advanced processes or technology.
sophisticated. See syn. study at rural.rural (antonym)
Suggesting the idyllic qualities of rural places or people
pleasant (related)
The definition of pleasant is someone or something that is agreeable, enjoyable or likable.
The Khoisan language of this people
(Scot.) A sturdy fellow
The definition of a hillbilly is someone who comes from a remote area with woods, hills or mountains.
A firefighter.
The definition of a redneck is slang and a derogatory term for a poor white person, often who lives in the rural Southern United States and who often has conservative or bigoted attitudes.
town (antonym)
Town means relating to a residential area that is smaller than a city and larger than a village.
urban (antonym)
Of or characteristic of the styles and culture of the inner city, esp. of the black inner city
couth (antonym)
(Archaic) Known; familiar
ability (related)
(Countable) A skill or competence in doing; mental power; talent; aptitude. [First attested in the early 17 th century.]
Find another word for rustic. In this page you can discover 85 synonyms, antonyms, idiomatic expressions, and related words for rustic, like: bucolic, uncouth, honest, natural, unaffected, refined, rural, arcadian, pastoral, peasant and countrified.

subset: commoncrawl


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For Dog Lovers
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Colorful products for dog lovers are certainly on our list of favorites. Don't just settle for average or boring products. Enjoying your favorite colors and themes should be a source of pleasure in your daily life. We curate products placing color at the forefront. Be happy, feel good, join us!


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Results from on-the-ground efforts to promote sustainable cattle ranching in the Brazilian Amazon.
Agriculture in Brazil is booming. Brazil has the world's second largest cattle herd and is the second largest producer of soybeans, with the production of beef, soybeans, and bioethanol forecast to increase further. Questions remain, however, about how Brazil can reconcile increases in agricultural production with protection of its remaining natural vegetation. While high hopes have been placed on the potential for intensification of low-productivity cattle ranching to spare land for other agricultural uses, cattle productivity in the Amazon biome (29% of the Brazilian cattle herd) remains stubbornly low, and it is not clear how to realize theoretical productivity gains in practice. We provide results from six initiatives in the Brazilian Amazon, which are successfully improving cattle productivity in beef and dairy production on more than 500,000 hectares of pastureland, while supporting compliance with the Brazilian Forest Code. Spread across diverse geographies, and using a wide range of technologies, participating farms have improved productivity by 30-490%. High-productivity cattle ranching requires some initial investment (R$1300-6900/ha or US$410-2180/ha), with average pay-back times of 2.5-8.5 years. We conclude by reflecting on the challenges that must be overcome to scale up these young initiatives, avoid rebound increases in deforestation, and mainstream sustainable cattle ranching in the Amazon.Open preprint
Advisory Board
- Leisa Armstrong, Edith Cowan University, Australia
- Arianna Becerril García, Autonomous University of the State of Mexico, Redalyc/AmeliCA, Mexico
- Susmita Das, Bangladesh Agricultural Research Council
- Abeer Elhalwagi, National Gene Bank, Egypt
- Gopinath KA, Central Research Institute for Dryland Agriculture
- Niklaus Grünwald, USDA Agricultural Research Service
- Sridhar Gutam, ICAR IIHR/Open Access India
- Vinodh Ilangovan, Max Planck Institute for Biophysical Chemistry
- Jayalakshmi M, ANGRAU, India
- Khelif Karima, Institut National de la Recherche Agronomique d'Algérie
- Dinesh Kumar, Indian Agricultural Statistics Research Institute
- Satendra Kumar Singh, Indian Council of Agricultural Research
- Devika P. Madalli, DRTC/Indian Statistical Institute, India
- Prateek Mahalwar, Cellulosic Technologies UG, Germany
- Bernard Pochet, University of Liège - Gembloux Agro-Bio Tech
- Vassilis Protonotarios, NEUROPUBLIC
- Andy Robinson, CABI
- Paraj Shukla, King Saud University
- Chandni Singh, Indian Institute for Human Settlements
- Kuldeep Singh Jadon, ICAR-Central Arid Zone Research Institute, India
- Rajeev K Varshney, CGIAR/ICRISAT, India
- Sumant Vyas, ICAR- National Research Centre on Camel, India
- Oya Yildirim Rieger, Ithaka S+R/ITHAKA, USA


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Additional information
#3/0, #5/0, #7/0, #9/0
#3/0 3PC per BAG, 6BAG per BOX
Right Hook for the Big Game Fishing!
Small differences in your setup can change the result.
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4 branded Kevlar braided assist line can endure sharp tooth of saltwater species, and the tough solid ring can resist the attack of yellowtail and various tuna.
Tying is done in details and covered with tube for increased durability.
Blue appeal type hook has Glow Tinsel line to maximize its appearance in the deep ocean.
◆ Hook Sizes


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Martin Gundersen
The 1980 Topical Meeting on Infrared Lasers was held December 3-5 at the University of Southern California, Los Angeles, California. Approximately 100 people registered for the meeting, 43 papers were presented, and there were two panel discussions. The meeting was supported by the U.S. Army Research Office, the U.S. Department of Energy, the National Science Foundation, and the U.S. Office of Naval Research.
Other content is not available for issues prior to 2002. Please contact email@example.com to request specific articles.
A Laser Test of Facemask Effectiveness
Structural Color—from Fat
Fluorescent Materials Glow Bright


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Dandelion Wishing Clock of the Adelaide Hills Sauvignon Blanc 2018
Free delivery Australia wide
On any purchase of a dozen or more
Personalised Service
With experienced wine nerds ready to help
Easy & Secure Shopping
No risk online shopping
Wine Goodness Guarantee
Didn't like the wine? Just send it back!
Adelaide Hills, SA
Sauvignon Blanc
Elena Brooks
Dandelion Vineyards
It wouldn't be dinner if wine wasn't involved - would it?? No truer words spoken than these current times.
What a delightful spicy starter. Perfect with an old Riesling, but for the young at heart!
Ingredients2 teaspoons vegetable oil 12 large uncooked prawns, shelled and deveined, leaving tails intact 2 teaspoons white sugar 1 tablespoon fish sauce 1 tablespoon lime or lemon juice 2 tablespoons chilli jam 1 fresh small red chilli, sliced thinly 1 stick fresh lemon grass, sliced thinly 4 shallots or small red onion, sliced thinly 2 teaspoons thinly sliced fresh ginger 4 fresh kaffir lime leaves, sliced thinly ½ cup loosely packed fresh coriander leaves, chopped coarsely 2 spring onions, sliced thinly ⅓ cup tamarind juice ½ cup loosely packed fresh mint leaves
MethodHeat oil in wok; stir-fry prawns until prawns change colour. Add sugar, fish sauce, lemon juice, chilli jam and toss to combine. Add chilli, lemon grass, shallots, ginger, lime leaves, coriander,
Classic Thai noodles, with option to sizzle your tongue with a dose of habanero chilli. Not for the meek!
Ingredients24 large king prawns 150ml fresh tomato sauce 600g chicken strips 15ml tamarind concentrate 300g julienne onion 30ml ABC soy 180g bean sprouts 40g castor sugar 3 bunches pak choy 3 cloves garlic 300ml pad thai sauce 1 dried chilli 60g preserved turnip 40ml oyster sauce 3 each haberno chilli (optional) 30ml fish sauce 2pkt rice stick noodles (soaked in warm water till soft) 5ml sesame oil 120g roasted crushed peanuts pinch paprika 60g fried shallots
Method1. Heat oil in wok until smoking 2. Add prawns & chicken. Fry for 30seconds. Add onion. 3. Strain oil & return prawns, chicken & onion to wok. 4. Add sliced haberno chilli, pad thai sauce, caramelised onion and preserved turnips. 5. Add noodles & cook till coated in sauce.
Coconutty, fishy goodness; a great Thai dish and that is much simpler to prepare than you might think...
Ingredients½kg Salmon 3 cups coconut milk 3 tablespoons fish sauce 2 tablespoons palm sugar Chopped kaffir leaves Coconut cream Chilli Paste: 5 dried chillies 1 teaspoon galangal 1 tablespoon chopped lemon grass 5 shallots 7 cloves garlic ½ teaspoon kaffir lime peel 1 teaspoon coriander root 1 teaspoon salt 1 teaspoon shrimp paste
Method1. Pound chilli paste ingredients until fine 2. Cut salmon into 2 pieces 3. Heat 1 cup of coconut milk over medium heat (keep stirring) 4. Add 1 cup of coconut cream, heat until oil appears on top. 5. Add chilli paste and mix until fragrant. 6. Add 2 cups coconut milk and heat. 7.Season to taste with fish sauce and palm sugar. 8. Grill salmon until cooked, top up with chilli paste sauce. 9. Garnish with kaffir lime leaves.
Dandelion Vineyards make wines from the McLaren Vale, the Barossa, Eden Valley, Adelaide Hills and Fleurieu Peninsula.
It wouldn't be dinner if wine wasn't involved - would it?? No truer words spoken than these current times.
Considerably cooler than the surrounding plains, the hills are washed in rain during winter months, and the peaks wrapped in fog. It is considered a high rainfall region compared to other Australian regions, but outside of winter the climate is warm and dry. Night time temperatures are the feature - notably cooler than the day when the sun sets. Worth noting is how the average rainfall increases the higher you go, with Mount Lofty picking up 1400mm on the old splash-o-meter compared to 850mm just 10K down the road in Charleston. This range of moisture and altitudes results in a variety of soils, but in general are sand and clay loam over clay subsoils. A bit of shale and ironstone can be found, and the soil is acidic on average and rarely acidic.
The combination of climate and soil lends to superb cool-weather whites like Riesling (if you watch for mould), Sauvignon Blanc, Pinot Noir and crisp Chardonnays. Merlot, Shiraz, Cabernet Sauvignon can also be found, with the grapes
Dandelion, Sister's Run, Heirloom Vineyards, Cien y Pico
Elena originally hails from Lyaskovets, Bulgaria, a small town famous for its wine. She is a qualified winemaker, BSc (Oenology) Adelaide and has made wine for various Australian Wineries as well as being a consultant winemaker to a number of leading wine companies in Spain, Italy and Bulgaria.
Born to a MIG Fighter Pilot and Helicopter Mechanic (both of whom happened to be involved in the wine industry in Lyaskovets), Elena's interest in winemaking stemmed from time spent translating for Australian Winemakers Stephen Bennet, David Norman, Dylan Rhymer, Kym Milne MW and others, who worked at her mother's winery between '93 and '98.
With Stephen Bennet's support and her family's encouragement, Elena made the move to Australia and started studying winemaking at Adelaide University in 1998, graduating in 2001 with a Bachelor of Science (Oenology). (Elena's mum was
Sauvignon Blanc is a green-skinned grape variety which originates from the Bordeaux region of France. The grape gets its name from the French word sauvage ("wild") and blanc ("white") due to its early origins as an indigenous grape in South West France. It is now planted in many of the world's wine regions, producing a crisp, dry, and refreshing white varietal wine.
In Australia
Here in Australia, particularly the Margaret River region, the grape is often blended with Sémillon. Varietal styles, made from only the Sauvignon blanc grape, from Adelaide Hills and Padthaway have a style distinctive from our New Zealand neighbours and tend to be more ripe in flavor with white peach and lime notes and slightly higher acidity.
Depending on the climate, the flavor can range from aggressively grassy to sweetly tropical. Wine experts have used the phrase "crisp, elegant, and fresh" as a favorable description of Sauvignon blanc from the
Sister's Run 'Cow's Corner' Barossa Grenache Shiraz Mourvèdre 2017Special Price $18.00 Regular Price $22.50
Dandelion Pride of the Fleurieu Peninsula Cabernet Sauvignon 2017Special Price $22.00 Regular Price $30.00
Dandelion March Hare of the Barossa Mataro 2018Special Price $50.00 Regular Price $60.00
Dandelion Lioness of McLaren Vale Shiraz 2017Special Price $22.00 Regular Price $30.00
Dandelion Lion's Tooth of McLaren Vale Shiraz Riesling 2017Special Price $22.00 Regular Price $30.00
Dandelion Wonderland of the Eden Valley Riesling 2013Special Price $22.00 Regular Price $30.00
Dandelion Lion's Tooth of McLaren Vale Shiraz Riesling 2018Special Price $22.00 Regular Price $30.00
Dandelion Twilight of the Adelaide Hills Chardonnay 2019Special Price $22.00 Regular Price $28.00
Dandelion Lionheart of the Barossa Shiraz 2018Special Price $22.00 Regular Price $30.00
Dandelion Fairytale of the Barossa Grenache Rosé 2018Special Price $18.00 Regular Price $30.00
Dandelion 'Firehawk Farm' McLaren Vale Shiraz 2017Special Price $50.00 Regular Price $60.00
Dandelion Enchanted Garden of the Eden Valley Riesling 2017Special Price $22.00 Regular Price $27.50
Dandelion Menagerie of the Barossa GSM 2017Special Price $22.00 Regular Price $30.00


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Mindbody Business 4+
MINDBODY Inc.
- Free
Mindbody Business app lets you easily manage and run your business from anywhere with instant access to your most important information: clients, schedule, point-of-sale, and business metrics. Your staff can manage their own schedules and see who's signed up for classes and appointments on-the-go directly from any iPhone or iPad. You can even fill empty spots and increase client engagement with shareable links that promote your business and schedule through your social networks. Whatever comes your way, with the Mindbody Business app, you'll always be ready.
With your Mindbody username and password, you can use the app to:
- Run your business smoothly with you and your staff's schedules at your fingertips.
- Drive in-person sales with an easy to use point-of-sale experience .
- Eliminate long lines at your front desk by checking clients in.
- Provide clients with a personalized experience by quickly viewing their information, including purchases and visit history.
- Always keep track of how your business is performing with access to real-time metrics and reports.
Please note: This app is for businesses that use Mindbody.
What's New
Version 6.2.1
- Easily start a live stream from your device - use the new start live stream button in the class details page
- Improved search to reduce the possibility of adding a new duplicate client account
- Additional timezone details for staff members in a different time zone on the class details page
Ratings and ReviewsSee All
Business on the
Simply an essential tool if you manage your business remotely or have other commitments that brings you away from your business. The ability to use multiple tablets at once multiples your points of sale
App drops offline
The app as a whole is great but at times it drops off and you have to cancel it or log back in. It happens at least once a week.
Great app!
Mindbody express is a fab way to manage bookings & make any last minute changes to schedule. It's also very useful to be able to check a clients schedule history etc on the app.
- Provider
- MINDBODY Inc.
- Size
- Category
- Business
- Compatibility
Requires iOS 12.0 or later. Compatible with iPhone, iPad and iPod touch.
- Languages
- Age Rating
- 4+
- Copyright
- Copyright ©2001-2019 MINDBODY
- Price
- Free
Family Sharing
Up to six family members will be able to use this app with Family Sharing enabled.


text:
Customer Testimonials
Always great products, and fantastic service!
Helpful and expertise.
Service is fantastic, specifically Jake and his knowledge
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Selection of bikes. People that know the business. Mechanical service.
Nice store and nice staff!!!! I recommend there.
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Wonderful customer service & can't say enough good things of the staff. So helpful & patient!
We shopped at Eddy's Bike Shop because we knew that, although it would be a bit more expensive than a big box store, we would receive personal assistance and value from the folks that worked there that we could not get anywhere else.
Everything! Customer service is great, knowledgeable and always have a positive attitude!
I have a bicycle addiction and Eddy's feeds it!
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When I brought my bicycle in to to the shop Eddy's explained what was wrong with the bike, what they needed to do and how much it would cost to fix it. They did all of this before I left the store. The bike was fixed in one day and I picked it up 24 hours after I brought it in to the store.
They then explained what they had done and explained that they tightened up the brakes, which they did at no charge. They even had the old part available for me if I wanted it.
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Eddy's carries thr Trek and Specialized bike lines which are my favorite. I know Jim Ruggles and his son and have bought many bikes from the Eddys family and will continue to do so for many years.
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Excellent customer service. They take a sincere interest in getting to know their customers then assess their needs in helping the customer make the best choice. I have three youth who have purchased bikes from Eddy's Bike Shop as I am extremely satisfied with their service. The staff also provide important tips regarding safety and proper bike maintenance. Friendly store environment.
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Great customer serv ice!
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The associate that greeted me when I walked in and then helped me find my item was extremely helpful, knowledgeable, and polite.
Fast and excellent service


text:
High Court of Judicature at Allahabad
Case Details
SHIV RAJ SINGH & OTHERS versus STATE OF U.P. & ANOTHER
Case Law Search
Indian Supreme Court Cases / Judgements / Legislation
Shiv Raj Singh & Others v. State Of U.P. & Another - APPLICATION U/s 482 No. 17242 of 2005 [2005] RD-AH 6679 (30 November 2005)
Hon. K.N.Sinha,J.
Heard learned counsel for the applicant and learned A.G.A.
Issue notice to respondent No.2.
Counter affidavit may be filed within four weeks. Rejoinder affidavit, if any, may be filed within two weeks thereafter.
List thereafter.
Meanwhile, further proceedings of Criminal Case No. 17/ 2005, State Vs. Satya Prakash and other, pending in the court of Chief Judicial Magistrate, Etah shall remain stayed till the next date of listing.
Dt. 30.11.2005.
Reproduced in accordance with s52(q) of the Copyright Act 1957 (India) from judis.nic.in, indiacode.nic.in and other Indian High Court Websites
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Black Resurrection
Glenn UndergroundStrictly Jaz Unit Muzic
Deep Within
Star Gate
Look Inside
Out Of My Mind
Star Gate
Star Gate Mystic Heard Piano Dub (11:20)
Star Gate Mystic Heard Piano Dub (11:20)
Mental Black Resurrection
Piano Dub (10:14)
Piano Dub (10:14)
One of the most amazing albums from Chicago's Glenn Underground, BLACK RESURRECTION is a timeless, soulful blend of cosmic keys, earthy production, jazzy rhythms, soulful beats, and dreamy vocals. It's a mix of top tier grooves and remixed versions of original tracks featuring GLENN's signature style of soulful jazzy deep house, brilliant keyboard playing and clean Afro beats. Includes "Deep Within", "Star Gate", "Mental Black Resurrection", "Soul Heights", "Look Inside", "My Little Ebony", "Play Play Play", "Sessions Of the Soul", "Spiritually Speaking", "Out Of Mind".
More from Strictly Jaz Unit Muzic
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PROJECT GU aka CVO & Boo Williams Strictly Jaz Unit Muzic
Love Sought After G.U. feat. Swaylo Strictly Jaz Unit Muzic
Stallions GU pres. SJU Strictly Jaz Unit Muzic
You Are Love GU feat. Swaylo Strictly Jaz Unit Muzic
Euphorian Orchestra Presents Euphoria Euphorian Orchestra Strictly Jaz Unit Muzic
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The Inner Circle: Zombies, Westerns and Horror, Oh My!
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The Inner Circle discusses the excitement and uniqueness certain of movie dramas.
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In active directory schema, it is allowed to add custom attributes. In organizations, there are situations where this option is useful. It is most of the time related to application integration requirements with active directory infrastructure. In … [Continue reading] about Step-by-Step guide to create custom Active Directory Attributes
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Irish-English dictionary. 2013.
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Luis Felipe Lopez-Calva is UN Assistant Secretary-General and UNDP Regional Director for Latin America plus the Caribbean
UN, Jul 26 2019 (IPS) – sex inequality is mostly about energy asymmetries. When you look at the belated 1970s, Robert Putnam reflected in the status of females in policy choices inside the study that is comparative on elites. Quoting Elizabeth Vallance, he determined that, "where energy is, women aren't.".
The task for attaining sex equity by rebalancing energy has got to be addressed in numerous spheres: your family, industry, and culture most importantly.
Luis Felipe Lopez-Calva
Happily, in the last several years the face area of politics changed in several Latin American and Caribbean nations. Not just have actually females been elected to your office that is highest often times in Latin America additionally the Caribbean since 1990—but females representation can also be expanding across multiple policy arenas through the nationwide to your regional degree.
As shown in Graph 1, from (circa) 1997 to (circa) 2019 the share of females in crucial policy arenas, such as for example parliament, ministerial case, together with supreme court, has almost tripled. Continue reading


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Chest pain is a frequently encountered emergency room presentation, of which about 15% of cases are due to acute coronary syndromes. Cardiogenic shock is a relatively uncommon complication with associated high morbidity and mortality. Emergency medicine practitioners frequently encounter critically ill patients that require quick, definitive treatment to optimize patient outcomes. These high acuity presentations often are of relatively low occurrence which makes training residents and learners challenging.
Simulation-based medical education has been shown to enhance patient outcomes by teaching these high acuity low occurrence (HALO) presentations in a safe environment. Herein we describe a simulation scenario of a patient with cardiogenic shock secondary to acute coronary syndrome. It consists of a step-wise, detailed summary of the case, along with modifiers to adjust the case for repeated use, learning objectives, and a suggested evaluation.
Ischemic heart disease (IHD) is the leading cause of death among adults in Canada, with more than 600,000 people dying annually [1]. Coronary artery disease (CAD) accounts for the vast majority of patients with IHD. The main symptom of CAD is chest pain, which results in over 8 million presentations to the emergency department annually [2]. Of those, approximately 15% have acute coronary syndrome (ACS), a third of whom have an acute myocardial infarction (MI) [3]. About 5-10% of patients with acute MI have cardiogenic shock, rendering it a rare but potentially lethal presentation.
Cardiogenic shock is the leading cause of in-hospital death in patients with acute MI [3] and seen in 4-8% of patients with ST-segment elevation myocardial infarction (STEMI) [4]. Depending on the area and extent of infarct, mechanical complications, including rupture of the septum, ventricular wall, or chordae tendinae, may or may not be present [5]. It occurs less frequently in patients with non-ST-segment elevation myocardial infarction (NSTEMI). About 10% of acute MI patients who will develop cardiogenic shock have it at presentation, with the median onset after arrival being approximately six hours. Cardiogenic shock is associated with a mortality of about 40%, with about half of the deaths occurring within the first 48 hours after presentation [6]. Therefore, early recognition of cardiogenic shock or ongoing myocardial ischemia is key for rural family medicine trainees. Early and effective management is key in restoring perfusion and optimizing patient outcomes.
People living in rural communities report higher levels of cardiovascular disease risk factors, including smoking, obesity, and inactivity compared to their urban counterparts. They also report higher levels of heart disease, hypertension, and stroke [7]. Due to a multitude of factors, cardiologists are less likely to establish a full-time practice in rural areas [8]. Consequently, rural patients have fewer overall visits to specialists and tend to rely heavily on care provided locally by primary care physicians. Predicting the clinical course in these critically ill patients can be quite challenging and determining whether a particular rural hospital has the capacity to care for such a patient is complex. Patients often want to remain local for treatment whenever possible, however, transport to a tertiary care centre sometimes becomes necessary [9].
Presently, teaching around this subject is largely didactic. Continuing medical education (CME) courses such as advanced cardiac life support (ACLS) offer a mix of didactic lessons and simulated cases. Simulation-based medical education has been repeatedly shown to affect learner skills, knowledge and attitudes, and patient outcomes [10]. It serves as a medium to teach high acuity low occurrence (HALO) and crisis resource management (CRM) skills and presentations in a safe environment. As such, it has become a mainstay of many postgraduate medical training programs. Recently, with the transition to the Competency by Design initiative for all Canadian postgraduate medical education programs, simulation will likely take a more predominant role in assessment.
This technical report is designed to train rural family and emergency medicine trainees in recognizing cardiogenic shock and quickly initiating the appropriate management steps. The objectives of this simulation scenario are:
1. Develop an approach to a patient with chest pain.
2. Communicate effectively with team members in the care of a complex, critically ill patient.
3. Recognize and manage evolving chest pain and cardiogenic shock.
4. Develop an approach to intubation in a patient with cardiogenic shock.
This report will be presented according to the Context-Inputs-Process-Product model [11].
Technical Report
This simulation scenario was designed for the training of rural family or emergency medicine residents. However, any learner, rural or urban, who attends calls as part of a hospitalist rotation, whether undergraduate or postgraduate, may benefit from participation. It was designed to take place in a community hospital with no subspecialty backup in-house.
The scenario is run with the help of a confederate, an individual who, during the course of the scenario, provides assistance with equipment, provides information about the mannequin not available in other ways (e.g. temperature, colour change), and/or to provide additional realism by playing the role of a relative or staff member [12].
Three to four residents participate in the scenario, one as a team leader and the others in additional roles. If the scenario is run with only one resident, the resident is to assume the role of team leader and available confederates (e.g. nurses, respiratory therapists, other physicians, etc.) can be used as the additional team members.
Two facilitators, who were familiar with the scenario and its management, were present during the scenario. One ran the scenario, took notes, and provided prompts as needed. The other acted as a nurse confederate assisting with the scenario in order to meet the learning objectives. They performed tasks for the learners as requested and delivered results and prompts to the learners when needed. When fewer residents are available to partake in the simulation, more confederates may be used to assist the learners.
The simulation session was conducted in a simulation lab using a Laerdal SimMan 3G® human patient simulator. The lab was outfitted with equipment, medications, and supplies typically available on a crash cart as well as those needed specifically for this case. The equipment and supplies are used only for simulation and teaching but are the same as what would be used in the hospital. The simulation lab is separate from the hospital and all equipment is clearly marked. The equipment provided included the following items:
- Advanced cardiac life support defibrillator and standard medications
- Airway supplies including oxygenation, intubation supplies, and suction
- Hospital chart and electrocardiograms (EKG)
- Intravenous (IV) access supplies and fluids
- Cardiac and oxygen monitors
- Medications, including vasopressors and inotropes
Higher fidelity simulation, defined as the level of realism associated with a particular simulation activity, is typically desirable. It is normally achieved by manipulating the realism of the simulator, the environment, or the scenario itself [13]. Lower fidelity simulators can be substituted for practice and integration into the scenario.
One week prior to the session, a step-wise, detailed scenario template (Table 1) was generated and reviewed by the scenario facilitators. This allowed for programming of the mannequin as well as preparation of supporting materials for the scenario itself. In addition, this provided some time for the facilitators to review the scenario and complete a dry run of the scenario to identify any potential problem areas.
A pre-briefing was held with all learners prior to the case. Learners were given a brief orientation to the simulation lab and mannequin. Limitations of simulation were reviewed, in particular addressing technical issues with the mannequin and resource availability. The fiction contract was addressed. This concept, also known as the "suspension of disbelief", encourages healthcare trainees and instructors to accept the simulation exercise as being real for the duration of the scenario in order to make it worthwhile [12]. Finally, learners were advised that the case was strictly formative.
Pre-scenario Information
You are a resident working overnight in the emergency department of your community hospital. A nurse from the inpatient ward comes to your office with an EKG from a patient who was admitted earlier in the day and is currently complaining of chest pain.
The Simulation
Table 1 depicts a step-wise, detailed scenario that was submitted to technical staff to run the simulation. Investigations that may be ordered, including EKG (Figure 1) and a chest radiograph (Figure 2) are provided upon learner request.
Debriefing and Post-Scenario Didactics
Following the conclusion of the scenario, facilitators and learners participated in a debriefing session. The debriefing was led by an experienced educator. Care was taken to ensure that the number of instructors to learners was approximately 1:1. Multiple debriefing models have been validated and choice usually is dictated by facilitator preference [16]. In this particular scenario, a modified plus/delta model was used [12]. Confederates and any simulated patients attended the start of the debriefing session to provide and receive feedback.
The content of the debriefing session was guided by the case learning objectives, yet it was a fluid process to accommodate the evolving dynamics of the team behaviour. That is, depending on how the scenario evolves, modifications were made to address any learning needs that arise. In this session, residents were taught around what to expect clinically from each infarct territory, the importance of serial EKGs, and the management of cardiogenic shock in the context of an acute MI. Considerations, such as the use of small boluses, vasopressor initiation, and when to consult a specialty service were also covered. The use and contraindications of TNK and intubation techniques were discussed. An approach to chest pain, including a differential diagnosis of non-cardiac causes of chest pain was also discussed. Additional objectives may be included by individual facilitators depending on local goals of the session. In cases such as this where transfer may be required, there is an opportunity to discuss local protocols and considerations such as weather and resource management.
Modifiers for the case can be applied in a variety of ways to both adjust difficulty and allow repeated use of the case, highlighting different points at each encounter. Some such modifications are included in Table 2. One such modification could include death as the end scenario. Currently, there exists much discussion about the benefits of including death as an outcome in simulation-based medical education [17-18]. Depending on learner objectives, facilitators could include an unsuccessful resuscitation as an optional end to the case.
A 90-minute didactic teaching session was also included to provide further teaching on topics relating to the case objectives. The incorporation of teaching following the simulation has been shown to be superior to pre-simulation instruction alone [10]. This was broken down into 45 minutes immediately following the scenario and an additional 45 minutes in a separate teaching session the following morning.
The expected learning outcomes for each participant are outlined by the learning objectives for this case:
1. Develop an approach to a patient with chest pain
2. Communicate effectively with team members in the care of a complex, critically ill patient
3. Recognize and manage evolving chest pain and cardiogenic shock
4. Develop an approach to intubation in a patient with cardiogenic shock
Although this simulation was held as a formative session, a locally developed global rating scale was used to quantitatively assess the learning objectives. It is included in Table 3.
Following the scenario, an anonymous survey is circulated to all participants. This allows the facilitators to gather feedback from the participants over the next few days following the session. Examples of questions circulated are included in Table 4.
In over 70% of cases, cardiogenic shock is related to acute myocardial infarction with ST-segment elevation. The management of acute MI with or without cardiogenic shock is crucial for anyone practicing acute care medicine - both in rural and urban centres.
For example, medical trainees across multiple disciplines often have to complete off-service rotations in which on-call coverage of a medical floor is necessary. Therefore, the quick recognition and management of acute coronary syndrome, including acute myocardial infarction and cardiogenic shock is imperative.
Physicians practicing in rural locations tend to have broad scopes of practice and as such are responsible for managing such presentations until transfer to a tertiary care centre can be arranged [19-20]. Local considerations, such as weather, mode of transport, and resource availability become important and are easily included in the scenario.
This scenario was initially run in small groups (three to four learners per session) of rural family medicine residents and medical students. Scenario subject and learning objectives were not distributed prior to the session. Learners were encouraged to use any available resources - including books, ACLS algorithms, and web applications - during an emergency department or call shift. The didactic session focused largely on the aforementioned learning objectives, and a written handout was circulated to learners following the session. A second teaching session, within the subsequent two weeks, was held to incorporate some Point of Care Ultrasound (PoCUS) teaching around echocardiography. Feedback on the scenario was largely positive, in particular surrounding the management of cardiogenic shock. There were suggestions around in situ simulation of this case rendering it more realistic, but unfortunately, that was not possible at the time of the sessions. Instead, future sessions will incorporate some other allied health care professionals (including nursing and respiratory therapy) to work on team functioning along with the scenario.
Future work includes validation of the locally developed GRS as the simulation is repeated over time with different learners. This would allow for the provision of objective feedback to the learner in a structured approach. As well, this scenario is a part of a larger curriculum developed for rural and remote trainees and will evolve as required to reflect local learning objectives.
The development of this scenario in a step-wise fashion allows the simulation to react according to learner actions. The list of modifiers included in Table 2 allows for an easily adaptable scenario that can be repeated according to local learning objectives. Having a facilitator review the scenario in advance ensures that it is of reasonable difficulty for the intended learner group and allows instructors to identify any shortcomings of the scenario. Finally, the coupling of a formal debriefing with a didactic learning session allows for both the collaborative identification of knowledge gaps and process errors that may arise during the scenario.
The use of simulation in teaching rural medicine trainees to manage acute myocardial infarction and cardiogenic shock may close a learning gap. These situations can be very demanding and emotionally charged. Therefore, practice in a controlled environment can be beneficial for rural family medicine trainees, ultimately improving both learner comfort and patient outcomes. We have presented herein an acute STEMI with cardiogenic shock, along with scenario modifiers, and post-scenario didactics and teaching, designed for rural family medicine trainees.
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Chest Pain on the Ward: A Simulation Scenario for Rural Family and Emergency Medicine Trainees
Ethics Statement and Conflict of Interest Disclosures
Human subjects: Consent was obtained by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Article Information
Cite this article as:
Williams K, Crocker P, Dubrowski A (June 28, 2020) Chest Pain on the Ward: A Simulation Scenario for Rural Family and Emergency Medicine Trainees. Cureus 12(6): e8887. doi:10.7759/cureus.8887
Publication history
Received by Cureus: March 11, 2020
Peer review began: June 15, 2020
Peer review concluded: June 16, 2020
Published: June 28, 2020
© Copyright 2020
Williams et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Chest Pain on the Ward: A Simulation Scenario for Rural Family and Emergency Medicine Trainees
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Nyukki wrote:Sorry for not taking part this week, I was made redundant last Monday so have been rather preoccupied. Wife is naturally pretty upset so no gaming 'til I straighten things out. Really annoyed as I was particularly looking forward to Dimahoo, and my bartop will supposedly be ready next week. Will join in if I can.
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ninjainspandex wrote: I'm using a USB arcade stick if this means anything, should I be using something with dual analogue sticks? This guy makes it looks so easy, how frustrating
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