Futility – “I thought I was helping the patient, but I am making them worse. The resources to save this patient are not available here.”

• Adult mannequin• IV/IO• IV fluids• Oxygen nasal cannula• ETT

• CBC w or wo diff, blood smear• Blood (family members must

donate)• Medications: morphine, para-

cetamol, ketamine, ceftriaxone

Acknowledgement – Treating chronic problems and malignancy is a high-resource endeavor. Allowing a patient to die with comfort and dignity is part of providing care as well.

Ideal Emotional Response DURING Case Ideal Emotional Response AFTER Debriefing

EMERGENY MEDICINE 3: AML Developed by Jessica Schmidt, MD

IDEAL CASE FLOW: Specifics less important than flow – Remember goal is to allow frustration

KEY MEDICAL MANAGEMENT REMINDERS

Indications for emergentblood transfusion

Supplies

• Recognize the presentation of chronic symptomatic anemia

• Understand indications and potential complications of transfusion

• Recognize end of life and provide comfort

Ideal Medical Objectives

• Allow case to mimic slow pace often found in resource-limited medical environments. Case may take over 30 minutes to complete.

• Allow ample time for participants to overcome obstacles from difficulty in communication, slow sharing of information, resisting prompting in problem solvingas much as possible.

Keys to Reaching Desired Emotional Response

• Assess ABCs

• Determine acute or chronic anemia

• Physical exam findings in chronic anemia may include: conjunctival pallor, delayed cap refill, splenomegaly

• Physical exam findings in acute anemia may include: signs of trauma, melena or hematemesis, petechiae, active hemorrhage

• In chronic anemia, transfusion threshold is below Hb of 6-7, but should correlate with patient’s symptomology

• 1 unit prbc (300cc) should increase Hb by 1 g/dL

• Whole blood has high rates of hemolytic transfusion reaction, febrile reaction and even anaphylaxis

Keys to palliation

• Palliative care is defined by the WHO as “improvement in quality of life and relief of suffering for patients with incurable disease”

• Lack of understanding of palliative treatment and lack of availability of opiates severely restrict palliative options in most LMICs

• When providing palliative care, it is important to emphasize communication with the patient, their family and the entire health care team

PROCEED TO CASE PRESENTATION, EXPECTED INTERVENTIONS, AND OBSTACLES

Patient brought into ER with weakness

FIRST STATE

Patient brought into ER with weakness

FIRST STATEPatient continues todeteriorate, givenmorphine

SECOND STATEPatient dies in comfort

THIRD STATE

Patient initially improvesbut then deteriorates

SECOND STATEPatient codes, resuscitative measuresare futile

THIRD STATE

Severe anemia recognized,opt to transfuse patient

Patient withincreased distress

Severe anemia recognized,but palliation prefered

Patient withdecreased distress

EMERGENY MEDICINE 3: AML. Provide information only as it is requested

PROCEED TO AML DEBRIEFING SCRIPT

POTENTIAL INTERVENTIONS AND OBSTACLES

STOP CASE WHEN THE FOLLOWING ARE TRUE

CC: Fatigue

HPI: A 17 year old male patient in Kigali, Rwanda presents with ongoing fatigue for several weeks. No fevers, no rashes, no diarrhea.

PMH: None

FH: No issues

SH: Lives w/ parents and 4 siblings, subsistence farmers in rural village, traveled 2 days to reach referral hospital

Medications: None

Allergies: None

Pertinent Positives on Exam (assume normal if not noted)

GEN: Fatigued, small for stated age

HEENT: Pale conjunctiva, PERRL

RESP: Mild tachypnea, clear lungs with no crackles, no retractions

CV: Tachycardic, 2/6 flow murmur, warm extremities

ABD: Soft, no masses, mild splenomegaly

NEURO: Awake and alert but somewhat slow to answer

EXT: No edema

SKIN: Pale, scattered petechiae

Participants have encountered obstacles andfound ways towork aroundlimited resources

Participants have identified thattransfusion made patient worse and have explored palliative options

Participants have recognized that no treatment options for likely disease state are available

Enough time has passed to allow for sense that case takes longer to manage than at home

Initial Vitals: (ONLY GIVE WHAT IS ASKED FOR): Wt – 70 kg T 38.5 HR 134 RR 24 BP 94/60 O2 88% on RA

ExpectedIntervention Obstacle Possible

Solution(s) Outcome(s)

No labs after 5 pm

No blood bank

Only nasal cannula (no NRB, no BiPAP), no diuretics

Bone marrow biopsy very expensive, only one doctor in town can do it, will not be available until next week,no Hematologist in Rwanda, no treatment for leukemia available in Rwanda

Discuss in person w lab tech or clinically diagnose

Have family donate blood or ask family to collect blood from local blood bank in town

Intubate or allow for comfort measures

Assume diagnosis basedon smear or treat symptom-atically or allow for comfort measures; transfer to Kenya for cancer treatment (expensive)

Very low Hb, blasts/ determine need for transfusion

Initial improvement in patient status

If intubated, stabilized;if comfort measures, patient dies

1. Obtain cbc

2. Transfuse blood

3. Manage respiratory distress after transfusion

4. Work up for anemia

EMERGENCY MEDICINE 3 DEBRIEFING SCRIPT1

Remember: Goal of debriefing is not to lecture, but to facilitate discussion

1Adapted with permission from Eppich, W., & Cheng, A. (in press). Promoting Excellence And Reflective Learning in Simulation (PEARLS):Development and Rationale for a Blended Approach to Healthcare Simulation Debriefing. Simul Healthc.

Setting the Scene: “We are going to spend the next 20-30 minutes debriefing the case. We are going to focus our attention on the emotions encountered but will also address the management of the case. We also want to focus on how you overcame obstacles often encountered when managing a case like this in a resource-limited environment.”

Reaction: “How did that feel?” Pay attention to cues pointing to overcoming lack of knowledge with ability to use available resources.

Description/Clarification: “Can someone summarize what the case was about from a medical standpoint by taking us through what just happened? I want to make sure we are all on the same page.”

You may need to clarify and keep this moving by asking follow up questions. “What happened next?”

Application/Summary: “Is there anything you learned during the course of this case, that has changed your perspective about your experience abroad?”

End with each learner providing a take-home point from the case

Analysis:“Remember, the goal is to get the participants to discuss how they dealt with their perceptions of different views of death and futility. Be sure to explore these themes.

• “What obstacles did you encounter to providing the care you felt this patient needed?” • “How did this case differ than care the patient would likely receive at your home institution?” • “How might your reaction to the lack of resources or lack of treatment differ from that of the local providers?

How might they view your reactions?” • “Were there parts of the case you wished you would have changed or done differently” • “How did you feel about the final outcome of the case; how do you think the family felt?”

Framework for Formulating Effective Debriefing Questions – Choose one prompt from each column

Observation Point of View Question

I noticed that... I liked that... How do you all see it?

I saw that... I was thinking... What were the team’s priorities at the time?

I heard you say... It seemed to me... How did the team decide that...

AML Case Blood Smear Smear: no schistocytes, no parasites, + blasts