Blood Rush: A Race Against Time


He could barely hear anything over the ringing sound echoing in his ears. A tight knot had formed in his throat, his hands felt strange as if they were numb but he knew there was no time to waste. With trembling hands, he cleared blood that was flowing out of the patient’s wound. With the pressuring mounting with every passing second, he could feel himself perspiring as a drop of sweat formed and raced down his forehead, at the verge of dripping. He reminded himself to “stay calm”. However, it was a process easier said than done, as the blood flowed out of the wound, drenching the white gauze and coloring it a dark shade of crimson. Continue reading “Blood Rush: A Race Against Time”

Low cost, Durable, DIY US Model – No refrigeration required!

Author: Evan Strobelt

Looking for a great DIY model for ultrasound-guided peripheral IVs and central lines? After lots of research and testing, we’ve found the BEST combination of affordability, convenience, and durability in the form of this recipe published in this article in the African Journal of Emergency medicine.

Remember those days before medical school when you took on a (probably unpaid) job as a research assistant, pipetting DNA into agarose gels for electrophoresis? Well, that’s what inspired this agar gel which does NOT require refrigeration to set and will stay fresh and non-moldy, even when left at room temperature for WEEKS!

So, what are the benefits of this recipe compared to other models?

  • It’s cheap! One of these ultrasound models comes out at less than $5 worth of materials! Compare that to the commercial ultrasound models which cost over $500-$1000!!!
  • Materials are easy to come by. All you need is water, flour, and agar. Agar is sold at most grocery stores or Asian markets, and if you don’t want to leave the house to get it, you can also find it on Amazon!
  • It’s much more durable than other DIY models! The recipe included in this article could withstand ~20 needlesticks within a 1 cm radius before degeneration compared to a gelatin model which could only withstand ~3 needlesticks. If you want to make your model even more durable and make it resemble human tissue even more, consider doubling the amount of agar you add to the water (76 g instead of 38 g).
  • It doesn’t require refrigeration. Trying to make a ton of these for a large group of trainees? This is definitely your choice if your fridge is stuffed full already! No need to clean out that long-expired yogurt to make space!
  • It doesn’t spoil! The gelatine models I tested grew mold within 3 days, even when refrigerated! On the other hand, this agar model can go weeks without growing mold!

So, below is the materials list published in the paper. I made some changes to the steps to improve your chance for success!


  • Water (375 mL)
  • Agar 900 g/cm2 (19 g)
  • Flour (1/2 teaspoon)
  • Latex tube or long animal balloons to simulate vessels


  • Mix 375 mL cold water with 19 g agar.
  • Stir until agar is thoroughly mixed and suspended in water without clumps.
  • OPTIONAL STEP: Add dark blue food coloring.
  • Heat mixture until NEARLY boiling. Avoid boiling because it will form tiny air bubbles which are extremely difficult to remove later and form artifacts that the ultrasound will not be able to see through.
  • Sprinkle ½ teaspoon of flour into the mixture, trying to avoid clumping.
  • Stir flour into the mix until all clumps are dissolved.
  • Pour the ENTIRE mixture into your mold. DO NOT just use half of it. I tried doing this and both my mold gel and the other half in my pot ended up setting and I couldn’t use the rest of the mix to create the second layer. Also, I tried maintaining the unpoured mixture at a warm temperature and found it very difficult to maintain in a liquid state without a) boiling it and b) burning it. Just do it in 2 batches, it’s way easier and fool-proof.
  • Allow your mixture to set at room temperature (no fridge required!) for 20 minutes.
  • Prepare your vessels.
    1. If using latex tubing, this is the best way I found to make both ends water tight.
      1. Use a hot glue gun and fill one end with glue to close it off.
      2. Then pour water into the tube. Consider dying your water blue or red to simulate blood if you want!
  • Then, use your hot glue gun again to close the other end off with glue.
  1. If using animal balloons, this is the best way. Note that due to the low compliance/elasticity of these balloons, it is difficult to get to a thickness that would be ideal. You’ll likely only be able to get them to simulate very small tiny veins (good if you have an expert audience) or giant veins that are not very realistic and will likely collapse inside your model after a single poke.
    1. Tie off one end of the balloon
    2. Fill with water to desired vessel diameter (a challenging process).
  • Tie off other end of the balloon.
  • Place your vessels on top of the first layer of gel inside your mold.
  • Then repeat steps 1-6 to create your second mixture for placement.
  • Pour second mixture on top of first hardened agar and on top of your simulated vessels.
  • Allow second layer to harden for 20 minutes

The last thing to consider for your gel is whether you want to make it more opaque to ensure students absolutely can’t see through to the vessels. The idea is for them to find them on ultrasound only, otherwise it’s cheating! I found that the latex tubing was fairly well-concealed in the mixture as long as the tubing was ~1 cm deep. Some of the brighter-colored balloons were visible, even at greater depths. Consider adding in a dark blue food coloring to your mixed agar/water mixture (as indicated by the optional step above). This will effectively hide balloons of nearly every color and will definitely obscure any latex tubing.

I hope you enjoy this DIY ultrasound gel recipe! Let me know how it works for you! And if you have any other tips on how to make this even better, please share!



Earle M, De Portu G, DeVos E. Agar ultrasound phantoms for low-cost training without refrigeration. African Journal of Emergency Medicine. 6(1): 18-23.

The In-Flight Emergency

Author: Alexis Germain

Picture this. You’re flying to your brand new residency program with your brand new medical degree and your brand new responsibility. The dreaded announcement comes out over the intercom “Is there a doctor on board?”

With an incidence of 1 medical emergency out of every 604 flights, it’s not an entirely unlikely scenario you may find yourself in. And thanks to the Aviation Medical Assistance Act passed by congress in 1998 medical providers assisting during an in-flight emergency are considered good samaritans with liability protection. Simulating the in-flight emergency provides a versatile exercise in which a medical problem must be managed with limited resources, and can prepare students to face the constraints of in-flight medical care.

While the pathophysiology of medical problems in the air is often similar to that on the ground, there are some additional factors to consider. At cruising altitude the cabin is maintained at an air pressure approximating an 8000 ft elevation. Decreased air pressure in the cabin leads to expansion of trapped air and can lead to increased pressure that become significant in patients with recent abdominal or intraocular surgery, a preexisting pneumothorax or pulmonary bleb, sinus infection, or URI. The lower air pressure additionally leads to a mild hypoxia due to lower partial pressure of oxygen. Consider this when assessing shortness of breath, particularly in patients with COPD that may be chronically hypoxic. Prolonged stasis from long distance travel may predispose patients to DVT and pulmonary embolism. Traveling in general may be stressful. Consider dehydration, particularly in cases of syncope. 

First step, know what you’re working with! The following items are available on all domestic flights. Note that equipment can be highly variable on international flights. 

Contents of Domestic In-Flight Medical Kits 

Assessment supplies Sphygmomanometer, stethoscope, gloves
Airway and breathing Oropharyngeal airways, bag-valve masks (3 sizes), CPR masks (3 sizes), Oxygen capable of delivery at 2-4 L/min
Intravenous access Intravenous administration set, 500 mL saline solution, needles, syringes
Medications Analgesic tablets, nonnarcotic; antihistamine tablets; antihistamine, injectable; aspirin; atropine; bronchodilator inhaler; dextrose, 50%; epinephrine, 1:1,000 solution; epinephrine, 1:10,000 solution; intravenous lidocaine; nitroglycerin tablets
Basics First Aid Bandages, splints, AED
Other resources Ground based medical support

Flight attendants are certified in CPR

Maybe (items not required by law, but possibly available) Glucometer, antiemetics, anticonvulsants, and additional cardiac medications. Note, controlled substances are not carried on US planes. 

SOURCE: Nable JV et al. N Engl J Med. 2015;373(10):939-945, based on FAA requirements for all commercial airliners in the United States.


Ensure your simulation accurately depicts the constraints of in-flight medical care. Define a row and aisle.


1 simulator, 1 patient, 1 flight attendant (acts as the communication to the pilot and may assist with CPR), 1-2 fellow passengers

Medical Problem

The most common causes of requests for medical assistance are syncope or pre-syncope (37.4%), respiratory symptoms (12.1%), nausea or vomiting (9.5%), cardiac symptoms (7.7%), seizures (5.8%), and abdominal pain (4.1%). Choose a medical emergency that requires utilization of the on board tools available, and delegation of tasks within the medical response team. For instance a cardiovascular emergency requiring CPR may require the simulator to have a crew member provide compressions, and select a bystander as a timekeeper while he or she places an IV to administer epinephrine. A concise overview of the most common in-flight medical emergencies with suggested management and pertinent history can be found in the 2018 JAMA article titled In-Flight Medical Emergencies: A Review (

A challenge of this scenario is clearly and effectively communicating with the flight crew, pilot, and ground based medical support (GBMS). When an emergency is brought to the attention of the flight crew, they notify the pilot who then contacts ground based medical support. When a request for assistance from a medical provider goes out, the volunteer should approach the flight crew and clearly identify their name and credentials. Once a volunteer becomes involved his or her assessment and recommendations will be relayed down this chain of communication to GBMS. It may be effective to write down the information required to prevent details from being lost in translation.

Also consider how the un-involved passengers may impact the situation. More than ever it is important to maintain control over the scene, provide clear directions, and minimize the crowd around the patient. 

Decision Making:
Ultimately it is the pilot’s decision whether to continue on as planned with a request for EMS to meet at the gate, request expedited landing at the original destination, or divert and make an emergency landing. The final medical recommendation will come from GBMS. However, advice from medical providers on board can strongly influence the final decision. If the simulator does not provide a recommendation, have the flight crew prompt him or her after an initial history and physical. If the patient requires immediate treatment to prevent loss of life or limb, or is otherwise unstable a diversion may be necessary.

Many factors filter into the pilot’s decision to land the plane. For instance, aircraft often take off with more fuel than safe to land with. A safe landing may require dumping of fuel, which some aircraft are not capable of. In addition to operational concerns, a diverted landing may result in direct costs in the hundreds of thousands of dollars. 


Consider adding additional complications to the simulation, particularly if multiple providers are participating. This is an uncontrolled environment in which you are likely to have a large audience. Another passenger may panic creating a distraction, having a lower level provider attempting to take control of the situation, or getting pushback on the decision to divert the plane from crew or ground control. 

For additional practice with a case that is already fully written and ready for implementation check out the interactive case at the end of the SIMS Casebook which can be downloaded for free from the Apple Books Library.


DIY Hemorrhage Control Simulator

Author: Cannon Woodbury

You were just on your way to grab a quick snack from the break room when you hear the overhead announcement, “Trauma team to room 5, trauma team to room 5.” You speed walk over to the trauma room and arrive just as triage wheels a patient in with their right arm covered in blood-soaked blankets. The triage nurse announces “This is a walk-in with a possible stab wound or GSW, likely arterial” and just then removes the patient’s blankets to reveal the wound. Bright red blood spurts across the room, painting a thin red line down your scrubs from 5 feet away. What do you do next?

Continue reading “DIY Hemorrhage Control Simulator”

Oh, the Places You’ll Go…with sim!

Author: Alyssa Thomason

Picture this…

It’s your first year of med school – you’re eager, you’re excited, you’re ready to save some lives and change the world. Except you spend most of your day in class where you couldn’t feel further from that dream. You start to wonder how any of what you’re learning fits into your bigger picture. How can you be expected to figure out what is important without any context? As you complete your umpteenth flashcard this week, you yell “AM I EVER GOING TO USE ANY OF THIS?!”

In a mad grasp for relevance, you sign up for nearly every student group on campus. You thought that with a name like “SIMULATION SOCIETY” you’d end up in the matrix taking a quiz on red and blue pills. Instead, you learned about how to recognize disease, work in teams, and handle yourself in a crisis. It may just be playing doctor, but better to fumble talking over a case with your classmates rather than with a critically ill patient.

Continue reading “Oh, the Places You’ll Go…with sim!”

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