Chest Pain on the Ward 1 … · Learner Actions - Establish 2 IV - Draw blood work including VBG...
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Chest Pain on the Ward © 2015 EMSIMCASES.COM Page 1 This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. Section I: Scenario Demographics Scenario Title: Chest Pain on the Ward Date of Development: 01/08/2015 (DD/MM/YYYY) Target Learning Group: Juniors (PGY 1 – 2) Seniors (PGY ≥ 3) All Groups Section II: Scenario Developers Scenario Developer(s): Kyla Caners Affiliations/Institution(s): McMaster University Contact E-mail (optional): [email protected] Section III: Curriculum Integration Learning Goals & Objectives Educational Goal: To review an approach to chest pain in the admitted patient and to review resources available to junior learners when on call overnight. CRM Objectives: Seeks input from team members and calls for help as needed. Medical Objectives: 1. Advises nurse of tasks to perform prior to arrival at bedside. 2. Performs brief and appropriate history/physical. 3. Recognizes and treats CHF and evolving chest pain. Case Summary: Brief Summary of Case Progression and Major Events The case will begin with a phone call from the bedside nurse for a patient on the ward that the resident on call is covering. The resident will then arrive at the bedside to find a patient complaining of significant chest pain. The patient will be in some respiratory distress due to CHF. The patient’s initial ECG will show new T-wave inversion. The patient will prompt regarding ongoing chest pain and his ECG will evolve to show an anterolateral STEMI. The team is expected to recognize the evolving STEMI and initiate treatment and cath lab activation. Facilitators Required to Run Session Instructors: 1-2 (one to observe and debrief learners, one to run mannequin) *Simple case means one instructor could complete both roles Confederate nurse: 1 (to assist at bedside, cue learners to work of breathing) Sim tech: optional
Transcript of Chest Pain on the Ward 1 … · Learner Actions - Establish 2 IV - Draw blood work including VBG...
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ChestPainontheWard
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SectionI:ScenarioDemographics
ScenarioTitle: ChestPainontheWardDateofDevelopment: 01/08/2015(DD/MM/YYYY)
TargetLearningGroup: Juniors(PGY1–2) Seniors(PGY≥3) AllGroupsSectionII:ScenarioDevelopers
ScenarioDeveloper(s): KylaCaners
Affiliations/Institution(s): McMasterUniversityContactE-mail(optional): [email protected]
SectionIII:CurriculumIntegration
LearningGoals&ObjectivesEducationalGoal: Toreviewanapproachtochestpainintheadmittedpatientandtoreviewresources
availabletojuniorlearnerswhenoncallovernight.CRMObjectives: Seeksinputfromteammembersandcallsforhelpasneeded.
MedicalObjectives: 1. Advisesnurseoftaskstoperformpriortoarrivalatbedside.2. Performsbriefandappropriatehistory/physical.3. RecognizesandtreatsCHFandevolvingchestpain.
CaseSummary:BriefSummaryofCaseProgressionandMajorEventsThecasewillbeginwithaphonecallfromthebedsidenurseforapatientonthewardthattheresidentoncalliscovering.Theresidentwillthenarriveatthebedsidetofindapatientcomplainingofsignificantchestpain.ThepatientwillbeinsomerespiratorydistressduetoCHF.Thepatient’sinitialECGwillshownewT-waveinversion.ThepatientwillpromptregardingongoingchestpainandhisECGwillevolvetoshowananterolateralSTEMI.TheteamisexpectedtorecognizetheevolvingSTEMIandinitiatetreatmentandcathlabactivation.
FacilitatorsRequiredtoRunSessionInstructors:1-2(onetoobserveanddebrieflearners,onetorunmannequin)*SimplecasemeansoneinstructorcouldcompletebothrolesConfederatenurse:1(toassistatbedside,cuelearnerstoworkofbreathing)Simtech:optional
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SectionIV:ScenarioScript
A.ScenarioCast&RealismPatient: ComputerizedMannequin Realism:
Selectmostimportantdimension(s)
ConceptualMannequin PhysicalStandardizedPatient Emotional/ExperientialHybrid Other:TaskTrainer N/A
Confederates BriefDescriptionofRoleNurse To“call”teamaboutpatientonward,cueteamtorespiratorydistress
B.RequiredMonitorsEKGLeads/Wires TemperatureProbe CentralVenousLineNIBPCuff DefibrillatorPads CapnographyPulseOximeter ArterialLine Other:
C.RequiredEquipmentGloves NasalProngs ScalpelStethoscope VenturiMask TubeThoracostomyKitDefibrillator Non-RebreatherMask CricothyroidotomyKitIVBags/Lines BagValveMask ThoracotomyKitIVPushMedications Laryngoscope CentralLineKitPOTabs VideoAssistedLaryngoscope ArterialLineKitBloodProducts ETTubes Other:IntraosseousSet-up LMA Other:
D.MoulageDiaphoresisonmannequin.Patientcharttobeatbedside(createoneonyourownlocalchartnotestoberealistic–shouldincludealistofinpatientmedications,includingASA).
E.ApproximateTiming
Set-Up: 3min Scenario: 12min Debriefing: 15min
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SectionV:PatientDataandBaselineState
A.ClinicalVignette:ToReadAloudatBeginningofCaseYouarethejuniormedicalresidentoncallovernightcoveringforateamofpatientsyoudonotknow.
Yougetapagefromanurseontheward.
“Oneofmypatientsishavingchestpain…canyoucomeandseehim?”
B.PatientProfileandHistoryPatientName:AllanJackson Age:75 Weight:70kgGender: M F CodeStatus:FullChiefComplaint:ChestpainHistoryofPresentingIllness:AdmittedforNSTEMI,awaitingangiograminthemorning.ComplainsofsuddenonsetretrosternalchestpainassociatedwithSOB.Alsocomplainingofnauseaandsomediaphoresis.PastMedicalHistory: CAD Medications: ASA HTN Altace HCTZ Allergies:None.SocialHistory:Ex-smoker.FamilyHistory:None.ReviewofSystems: CNS: Nil
HEENT: NilCVS: RetrosternalCPwithsuddenonset.RESP: FeelsverySOBsinceCPstarted.GI: NauseasinceCPstarted.GU: NilMSK: Nil INT: FeelssweatyC.BaselineSimulatorStateandPhysicalExam
NoMonitorDisplay MonitorOn,nodatadisplayed MonitoronStandardDisplayHR:101/min BP:179/90 RR:30/min O2SAT:93%on35%Rhythm:Sinustach T:36.7oC Glucose:6.8mmol/L GCS:15(E4V5M6)GeneralStatus:Alertbutindistress.CNS: Alert,abletodescribehistory.HEENT: NilCVS: Nomurmur.RESP: Diffusecracklesthroughout.IncreasedWOB.ABDO: Soft,NT.GU: Nil.MSK: Nil.HasonePIVinsitu. SKIN: Mildlydiaphoretic.
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SectionVI:ScenarioProgression
ScenarioStates,ModifiersandTriggersPatientState PatientStatus LearnerActions,Modifiers&TriggerstoMovetoNextState1.CallfromwardHR:98/minBP:175/60O2SAT:91%RAT:Afebrile
RNcallswithvignette.Readsvitalsoutoverphoneifasked(butprovidesnootherdetails)
LearnerActions- AskRNforvitals- InstructRNtoplacepatientonoxygen- AskforECG- Askforchartatbedside- Goseepatient
ModifiersChangestopatientconditionbasedonlearneractionTriggersForprogressiontonextstate-ConversationendswithRNà2.ArrivaltoWard
2.ArrivaltowardRhythm:SinustachHR:101/minBP:179/90RR:30/minO2SAT:93%on35%T:36.7oC
Patientalertandabletoanswerquestionsshortsentences.Diaphoretic.
LearnerActions- Establish2ndIV- DrawbloodworkincludingVBGandtroponin- PortableCXR(unavailable)- ECG- Readthroughchart- Nitro0.4mgSLq5minx3- CallRTforBiPap- Lasix40mgiv±foley
Modifiers-PatienttocueaftereachnitrospraythatstillhavingCPTriggers-Nitrox3à3.Hypoxia-8minutesà3.Hypoxia
3.HypoxiaHRà98RRà40BPà160/85O2SATà88%
Patientcomplainsthatpainisworse.RNtopromptthatpatientlooksmoreSOB,CXRnowdone(CHF).
LearnerActions- RepeatECG- Startnitroinfusion(50mcg/minivtostart)- InitiateBiPap- CallcathlabforSTEMI- ASA160mgPOchew- Heparin4000mgiv- TicagrelororPlavixload- Prepareforintubation,callICUoranesthesia
Modifiers-NorepeatECGàRNtopromptTriggers-CathcalledàEndCase
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SectionVII:SupportingDocuments,LaboratoryResults,&Multimedia
LaboratoryResults
Noresultsgivenduringcase.
Images(ECGs,CXRs,etc.) OldECG
(ECGsource:http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)
InitialECGonward(AnterolateralTWI)
(ECGsource:http://hqmeded-ecg.blogspot.ca/2015/12/lvh-with-anterior-st-elevation-when-is.html)
RepeatECGonward(anterolateralSTEMI)
(ECGsource:http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/10/recent-anteroseptal.jpg)
CXR:CHF
(CXRsource:https://www.med-ed.virginia.edu/courses/rad/cxr/web%20images/into-chf.jpg)
UltrasoundVideoFiles(ifapplicable) Noneforthiscase.
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SectionVIII:DebriefingGuide
GeneralDebriefingPlanIndividual Group WithVideo WithoutVideo
ObjectivesEducationalGoal: Toreviewanapproachtochestpainintheadmittedpatientandtoreview
resourcesavailabletojuniorlearnerswhenoncallovernight.CRMObjectives: Seeksinputfromteammembersandcallsforhelpasneeded.
MedicalObjectives: 1. Advisesnurseoftaskstoperformpriortoarrivalatbedside.2. Performsbriefandappropriatehistory/physical.3. RecognizesandtreatsCHFandevolvingchestpain.SampleQuestionsforDebriefing
1. Whataresomeapproachestomanagingphonecallsfromthewardaboutpatientsyoudon’tknow?2. Whatwasthecauseofthispatient’schestpain?Howdiditfeeltomakethatdiagnosisonaward?3. Whatresourcesareavailabletoyouonthewardovernight?Whocanyoucallifyouarefeeling“in
overyourhead”?4. WhoshouldyoucallifyouhaveanadmittedpatientwithaSTEMI?Anadmittedpatientwhodies?
KeyMomentsInitialinstructionsoverthephoneRecognizingECGchangesCallingforhelp
