A 37F with no past medical history presents with wide complex tachycardia. She is initially stable, and after unsuccessful treatments, will decompensate either with hypotension or with polymorphic atrial fibrillation, and require synchronized cardioversion. After stabilizing the patient, she is revealed to have undiagnosed Wolfe-Parkinson-White.
The medical aspect of this case is a relatively straight-forward out-of-hospital cardiac arrest where the team must recognize futility and make the decision to stop resuscitation efforts. The primary goal is simulating the experience of making a termination of resuscitation decision, and managing the impacts of a patient’s death. Other goals could also be scaffolded onto this scenario as deemed appropriate by the simulation instructor, including breaking bad news to family member or a simulated hot debrief with the team.
This is the twelfth and final case in a series we are publishing that make up “The Nightmares Course” – a Sim Bootcamp for new residents. It is 3:00 am, you are called to the floor to assess a 73-year old man experiencing confusion, shortness of breath, and chest heaviness.
A 24-year-old previously healthy male presents to the ED with absent vital signs. He is out for a trail run when he becomes trapped in waist deep cold water. When he is found by search and rescue, he is awake with altered mental status. He has a cardiac arrest on retrieval and is found to be severely hypothermic. CPR and ACLS is initiated and he is transferred to the nearest community ED. The resuscitation team is expected to perform ACLS specific to hypothermic arrest. The patient will require intubation, active rewarming, defibrillation and discussion with the ECMO physician on call for transport and ECMO assisted rewarming.
This is the eleventh case in a series we are publishing that make up “The Nightmares Course” – a Sim Bootcamp for new residents. It’s 23:00 and you’re called to assess a 42-year old man who is difficult to rouse on evening rounds.
48-year-old male with a recent tracheostomy presents with sudden onset respiratory distress. The patient is unable to be oxygenated or ventilated through the tracheostomy tube. The team must recognize that the tracheostomy tube is either obstructed or displaced. Attempts to correct tracheostomy obstruction with suctioning and cuff deflation are not successful. Removal of the tracheostomy tube is required, followed by either oral intubation or placement of a new tracheostomy tube. The patient improves once oral or stomal intubation is performed. If tracheostomy tube is not removed, the patient worsens and goes into cardiac arrest secondary to respiratory failure.
Pre-notification is sent about an 8-year-old with known seizure disorder coming in via EMS who has been seizing for 7 minutes and is persistently seizing despite intramuscular midazolam. The case will involve managing pediatric status epilepticus and including escalating anti-epileptics, intubation, and handing over to pediatrics.
Securing the airway of a severely traumatized patient is fraught with difficulties. There can be anatomic difficulties associated with facial and neck injuries. There are often physiologic difficulties from uncommon causes of shock (like pericardial tamponade). But emergency physicians have all the skills needed to safely handle any trauma airway!
This is the tenth case in a series we are publishing that make up “The Nightmares Course” - a Sim Bootcamp for new residents. The Nightmares Course at Queen’s University (Kingston, Ontario) was developed in 2011 by Drs. Dan Howes and Mike O’Connor. The course emerged organically in response to requests from first year residents … Continue reading Nightmares Case 10: Anaphylaxis
A 67yr old male with multiple comorbidities is brought by ambulance with a 3-day history of diffuse abdominal pain. The history is vague and the differential of his symptoms remains very broad. He develops significantly worsening pain and hypotension and becomes obtunded. As the patient’s condition deteriorates, the team must initiate management of abdominal pain plus shock and support the hemodynamics with vasopressors/inotropes. The team will need to intubate to facilitate advanced imaging and definitive care.