Nightmares Case 2: Pneumonia

This is the second in a case series we will be publishing that make up “The Nightmares Course”.

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

Mr. Jim Smith is a 64 year old male that was admitted 3 days ago. He was diagnosed with a community acquired pneumonia and started on daily Moxifloxacin. The nurse is concerned about his increasing shortness of breath since she started the night shift 4 hours ago.

Case Summary

In this case, the patient has been admitted for pneumonia and treated with the usual antibiotics. However, the team has not yet recognized that the causative bacteria is resistant to this antibiotic. The pneumonia has progressed and the team must manage the patient’s respiratory distress and sepsis. The patient requires a change in antibiotics, non-invasive ventilatory support and IV fluid resuscitation.

Download the Case Here

Nightmares Course #2: Pneumonia

EKG for the Case

Pulmonary disease pattern COPD ECG

Chest X-ray for the Case

Chest X-ray:

Geriatric Case 6: Elder Abuse

This is the sixth and final case in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.

Dr. Rebecca Shaw is an emergency physician currently working as a medical education fellow within the Emergency Department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an emergency physician with a special interest in geriatric emergency medicine, medical education and simulation. She is trying her best to combine these interests to improve geriatric patient care across all health sectors. She is also an assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (

Why It Matters

Elder abuse and neglect is under-recognized, under-reported and under-treated. The emergency department provides an opportunity to identify and intervene in cases of elder abuse. Often, the signs of abuse may be subtle. This case gives participants the chance to improving their skill in identifying elder abuse and to practice their approach to this emotionally challenging issue.

Clinical Vignette

A bedside RN comes to you and says, “Nora has been brought into ED after a fall at home 3 days ago. She is a bit tachycardic and complaining of some pain in her abdomen. She has a few bruises on the rest of her body. Could you please assess her?”

Case Summary

An 80-year old woman presents after a fall at home. She is complaining of right sided upper abdominal pain since the fall. She is also complaining of intermittent palpitations and dizziness prior to the fall. Participants are expected to identify that the cause of the fall is due to elder abuse and to manage this along with her concurrent medical issues and abdominal injury.

Key to a Successful Simulation

This case uses a standardized patient who has an extensive script and back story. This patient needs to be familiar with the story and respond in character to the participants questions and empathy (or lack of empathy). There should be a slow unfolding of the story as the participants gain the patient’s trust.

Download the case here:

ECG for the case:

ECG Source: Dr Ed Burns,

Chest x-ray for the case:

Pelvis x-ray for the case:

RUQ ultrasound for the case:

U/S source: McMaster PoCUS Subspecialty Training Program