Table 3. Suggested case modifiers utilized to alter the difficulty of the simulation.

NSAIDs = Non-steroidal anti-inflammatory drugs; BUN = Blood urea nitrogen; INR = International normalized ratio.

FEATURE	MODIFIER & COMMENTS
Simulated Patient Confederate(s)
Family member	Knowledgeable & helpful
Friend	Loud, interfering & little knowledge
Historical Findings
Patient alertness	Alert, knows medications & history
	Altered level of consciousness. Not helpful regarding medications or medical history & must use alternate sources - Medical bracelet - Electronic medical records - Collateral history
Medications	Beta-blockers (effect on heart rate)
	Anticoagulants (effect on bleeding): - NSAIDs - Warfarin - Direct oral anticoagulants
Physical Examination Findings
Heart rate & rhythm	Sinus tachycardia (junior learners)
	Atrial fibrillation on monitor (A clue to patient potentially being on anticoagulants)
	No tachycardia (senior learner) - e.g. patient on beta blocker
Laboratory data
Abnormal values (junior learners)	May include the presence or absence of upper gastrointestinal bleed such as a low hemoglobin or increased BUN
Normal values (senior learners)	Normal lab values for hemoglobin and BUN; equivocal INR results
Procedural Integration (advanced learners) - either on the mannequin or a separate task trainer
Intubation
Central line placement	McNeil et al. provide a description of appropriate central venous catheter insertion [11].
Balloon tamponade device placement	Weingart has produced a video and tutorial demonstrating the proper insertion of such a device [12].
Simulation Outcome
Death as a potential endpoint	For the advanced learner and facilitators should decide beforehand if this will be a specific objective and potential outcome.