Clinical Decision-Making Case: Thyroid Storm
Correspondence should be addressed to Stephanie Stapleton, MD at snstaple13@gmail.com
DOI: https://doi.org/10.21980/J8.53003
ABSTRACT:
Audience: This clinical decision-making case is intended for all emergency physicians (EP) in training.
Introduction: Thyroid storm (TS) is a rare but life-threatening endocrine emergency that represents the most severe form of thyrotoxicosis. If not promptly recognized and appropriately managed, TS carries a mortality rate of up to 25%.¹ However, with timely and aggressive treatment, mortality can be significantly reduced to 1.2–3.6% in the United States.² Due to its rarity and often nonspecific presentation, early diagnosis and intervention in the emergency department are essential to improving patient outcomes. Recognizing its critical nature, the American Board of Emergency Medicine (ABEM) identifies thyroid storm as a core emergency condition that emergency physicians (EPs) must be trained to manage.³ Additionally, recent updates to the ABEM certifying examination emphasize the importance of clinical decision-making and the ability to verbalize diagnostic reasoning and management plans. This case has been designed to help learners practice and demonstrate these skills in the context of a high-stakes, time-sensitive clinical scenario involving thyroid storm.
Educational Objectives: By the end of the session, learners will be able to: 1) verbalize key pertinent historical and physical exam findings in a young female patient presenting with altered mental status; 2) formulate a prioritized differential diagnosis based on the history and physical exam; 3) order appropriate diagnostic studies and recognize abnormalities suggesting thyroid storm; 4) describe pathophysiology, management and rationale of sequential pharmacologic therapy in thyroid storm; 5) communicate patient’s medical care and course to family; and 6) review essential disposition actions including consultations and level of care for admission.
Educational Methods: We implemented a certifying exam board format case aligned with the ABEM’s updated certifying exam board examination. The case was co-developed by experts in simulation-based education and emergency medicine and underwent external peer review, which focused on the accuracy of the clinical context, clarity of scenario instructions, and educational value.
Research Methods: The case was iteratively developed and refined through multi-site piloting. Initial design was completed by three faculty with emergency medicine and simulation backgrounds, followed by external review using the Simulation Scenario Evaluation Tool (SSET). Feedback focused on case progression, realism, alignment with objectives, and consistency with assessment standards.
The case was then piloted at two academic training sites and at the Society for Academic Emergency Medicine (SAEM) Annual Meeting. Participants included faculty facilitators and EM residents. Residents and faculty completed a modified usability survey incorporating Likert-scale items (1 = strongly disagree to 5 = strongly agree) and open-ended comments. Data was collected in Qualtrics® and analyzed in Excel®. Revisions were made after each iteration to improve clarity, usability, and educational impact.
Results: The simulation scenario evaluation tool (SSET) evaluations were strongly positive. Facilitators (n = 3) consistently rated the case objectives, critical actions, and supporting materials as clear. They agreed or strongly agreed that the case was appropriate for the learner level, that the clinical course adhered to the ABEM format, and that the critical actions supported the stated objectives. Mean ratings ranged from 4 to 5 for ease of use, and facilitators noted that their colleagues would also find the materials accessible. They described the case as well-integrated, expressed confidence in facilitation, and endorsed its utility for ABEM certifying exam preparation.
Resident feedback was similarly supportive. Three learners unanimously agreed that the case provided helpful practice for the ABEM exam and reported that both the written and verbal instructions were clear.
Discussion: The thyroid storm clinical decision-making case proved to be an effective educational tool, meeting its intended objectives and offering meaningful preparation for emergency medicine residents facing the new ABEM certifying examination. Facilitators consistently reported that the case objectives, critical actions, and supporting materials were clear and aligned with the targeted level of learner training. Similarly, both facilitators and residents found the case to be a valuable exercise, providing relevant and realistic practice in the style of the certifying exam.
While early results are encouraging, future challenges and opportunities remain. In particular, the evolving structure and scoring approach of the new ABEM certifying examination introduces areas where additional refinement may be needed. As more information becomes available regarding the exam’s evaluation metrics, this case can be further tailored to enhance alignment and maximize its educational impact. Continued iterative development will ensure the case remains a practical and high-yield resource for residents as they prepare for certification.
Topics: Hyperthyroidism, communication, clinical decision-making case, certifying exam, thyroid storm, endocrinology.
