Nightmares Case 3: Seizure

This is the third 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

It is 01:00 and you are on call covering the thoracic surgery service. You have been called to assess Mr. Wright for a seizure episode.

Case Summary

The resident is called to the ward to manage a patient who may have had a seizure. The patient is somnolent when the resident arrives. Shortly afterward, the patient seizes again. Two doses of anti-epileptic will be required to terminate the seizure. Finally, when the patient has been stabilized, the resident will be required to discuss the case with their staff on call.

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Seizure

Nightmares Case 1: Bradycardia

This is the first 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

The triage note states – Patient “fainted” while returning from the bathroom at home. He was found to be slightly more confused by his wife and complained of right elbow pain.

Case Summary

This is a case of an elderly patient with syncope. He is found to be in third degree heart block.  The team is expected to perform an initial assessment and obtain an ECG. Upon recognizing the heart block, they should ensure IV access and place pacer pads while calling for help.

Download the case here:

Bradycardia

ECG for the case found here:

Brady.jpg

Source: https://www.ecgquest.net/ecg/complete-heart-block-3/

Geriatric Case 5: Trauma with Head Injury

This case is the fifth 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 (Simulationpodcast.com).

Why It Matters

Elderly patients who have sustained trauma are frequently encountered in the ED. These patients have unique physiology and are often complex due to frailty and polypharmacy concerns. Care of the elderly trauma patient requires attention to these complexities, to goals of care, and to communication with family members. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

The bedside nurse informs you that “EMS just off-loaded an elderly male to the resuscitation bay. He had a fall down the stairs and sustained a head injury. He was GCS 15 and hemodynamically stable when they picked him up, so they didn’t activate the trauma team, but he has deteriorated during transport. He has an obvious large, boggy scalp hematoma over the left parietal region. I am worried because he’s getting restless and won’t follow commands.”

Case Summary

An 81-year old man falls down the stairs at home. He is initially asymptomatic but his level of consciousness declines and he starts to show signs of raised ICP. Providers must recognize and treat this, as well as reverse his anticoagulation, provide neuroprotective RSI and safely transport to the CT scanner. Providers must then talk with the patient’s wife, to provide information on his condition and prognosis and discuss the patient’s goals of care.

Download the case here:

Geriatric Trauma with Head Injury

ECG for the case found here:

Geriatric Trauma ECG

ECG Source: https://en.ecgpedia.org/index.php?title=Atrial_Fibrillation

CXR for the case found here:

Geriatric Trauma CXR

Image courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 6410

Pelvic XR for the case found here:

Geriatric Trauma Pelvic XR

Image courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 28928

Learner-Consultant Communication

This case was written by Dr. Jared Baylis. Jared is currently a PGY-4 in emergency medicine at UBC (Interior Site – Kelowna, BC) and is completing a simulation fellowship in Vancouver, BC.

Twitter – @baylis_jared + @KelownaEM

Why It Matters

Referral-consultant interactions occur with regularity in the emergency department. These interactions are critically important to safe and effective patient care. Several frameworks have been developed for teaching learners how to communicate during a consultation including the 5C, PIQUED, and CONSULT models. This case allows simulation educators to incorporate whichever consultation framework they prefer into a simulation scenario that allows deliberate practice of the consultation process.

Clinical Vignette

You are a junior resident working in a tertiary care centre and you are asked to see a 58-year-old female patient who was sent in from the cancer centre. She is known to have metastatic non-small-cell lung cancer and has been increasingly dyspneic with postural pre-syncope over the last few days. Her history is significant for a previous malignant pericardial effusion that was drained therapeutically a few months ago.

Case Summary

In this case, learners will be expected to recognize that this 58-year-old female patient with metastatic non-small-cell lung cancer has tamponade physiology secondary to a malignant pericardial effusion. The patient will stabilize somewhat with a gentle fluid bolus but the learners will be expected to urgently consult cardiology or cardiac/thoracic surgery (depending on the centre) for a pericardiocentesis and/or pericardial window.

Download the case here: Learner-Consultant Communication

Checklists for 5C, PIQUED, and CONSULT frameworks: Consult Framework Checklists

FOAMed article on 5C framework: 5C CanadiEM

FOAMed article on PIQUED framework: PIQUED CanadiEM

ECG for the case found here:

ECG

(ECG Source: https://lifeinthefastlane.com/ecg-library/basics/low-qrs-voltage/)

CXR for the case found here:

CXR

(CXR Source: https://radiopaedia.org)

POCUS for the case found here:

 

(Ultrasound Source: https://www.youtube.com/watch?v=qAlU8qhC1cU)