Nightmares Case 11: Opioid Overdose

This is the eleventh 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 wanting more training in the response to acutely unwell patients. In 2014, Dr. Tim Chaplin took over as the course director and has expanded the course to include first year residents from 14 programs and to provide both formative feedback and summative assessment. The course involves 4 sessions between August and November and a summative OSCE in December. Each session involves 4-5 residents and covers 3 simulated scenarios that are based on common calls to the floor. The course has been adapted for use at the University of Saskatchewan, the University of Manitoba, and the University of Calgary.

Why it Matters

The first few months of residency can be a stressful time with long nights on call and the adjustment to a new level of responsibility. While help should always be available, the first few minutes of managing a decompensating patient is something all junior residents must be competent at. This case series will help to accomplish that through simulation.

Clinical Vignette

It’s 23:00 and you’re called to assess a 42-year old man who has been admitted to the orthopedics service for a right tibial osteomyelitis. He has had an initial debridement and is awaiting a second surgery in 48 hours. His nurse is concerned as he was difficult to rouse on evening rounds.


This case involves the identification and initial management of the opiate intoxicated patient. The resident is expected to initiate appropriate supportive measures (ensure working IV, oxygen, monitors) while obtaining a focused history and performing a focused physical exam. They should call for naloxone and help (RACE, anesthesia, ICU) due to decreased LOC and hypoxia.



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