Polytrauma for Team Communication

This case is written by Dr. Chris Heyd. He is a PGY4 Emergency Medicine resident at McMaster University and has spent the last year completing a sub-specialty focus in disaster medicine and simulation. He is also one of our resident editors here at EmSimCases.

Why it Matters

This case highlights some of the challenges that can be associated with activating a trauma team. While the intent is to have many expert hands available to help at once, sometimes the team members arrive in a staggered fashion. This case reviews:

  • The challenges of managing an unstable trauma patient when there are interruptions to the flow of communication
  • The need to expediently place a chest tube in a hypoxic trauma patient
  • The fact that near simultaneous intubation and chest tube placement is often necessary in an unstable trauma patient

Clinical Vignette

To be read aloud by simulation facilitator at start of case:

“You are working as an Emergency physician at a tertiary care trauma centre and have been called overhead to your trauma bay. A paramedic team has just arrived with a 64-year old trauma patient. He was involved in a highway speed head-on MVC. He was restrained and air bags deployed. He was the driver and the other drive died on scene. There were no other passengers. EMS extricated the patient easily. They have placed one IV line and started running normal saline. He has been placed on a non-rebreather mask but has remained tachycardic, hypoxic and altered. GCS has been consistently 14. The trauma team was activated based on injury mechanism but so far only the orthopedic resident has arrived at the bedside.”

Case Summary

A 64-year old man is involved in a high-speed car crash. The trauma team is activated and he is brought directly to the ED. On arrival, he is hypoxic, tachycardic and altered. CXR reveals multiple rib fractures with a right-sided hemopneumothorax.

The team leader will need to effectively communicate with the team to ensure the tasks of intubation, chest tube placement and blood product administration are performed in a safe and quickly. The patient will stabilize after these treatments.

Members of the trauma team will have a staggered entry into the room. The team leader will need to balance communication with the new team members and the urgent interventions needed by the patient.

Download the case here: Polytrauma for Team Communication

CXR for the case found here:

CXR trauma

(CXR source: https://radiopaedia.org/cases/large-traumatic-haemothorax)

PXR for the case found here:

Normal PXR

(PXR source: https://radiopaedia.org/cases/normal-pelvis-x-ray-trauma-supine-1)

Lung U/S showing hemothorax found here:

 

(U/S source: McMaster PoCUS Subspecialty Training Program)

Normal RUQ FAST image found here:

no FF

(U/S source: McMaster PoCUS Subspecialty Training Program)

Pregnant Cardiomyopathy

This case is written by Drs. Nadia Primiani and Sev Perelman. They are both emergency physicians at Mount Sinai Hospital in Toronto. Dr. Primiani is the postgraduate education coordinator at the Schwartz/Reisman Emergency Centre. Dr. Perelman is the director of SIMSinai.

Why it Matters

Most emergency physicians have some degree of discomfort when a woman in her third trimester presents to the ED for any complaint. When that woman presents in acute distress, the discomfort is increased even further! This case takes learners through the management of a patient with a pregnancy-induced cardiomyopathy, reviewing:

  • The importance of calling for help early
  • The fact that all pregnant patients at term must be presumed to have difficult airways
  • That the treatment of the underlying medical condition is still the primary focus – in this case, BiPap, definitive airway management, and ultimately, inotropic support

Clinical Vignette

You are working in a community ED and your team has been called urgently by the nurse to see a 38 year old female who is G2P1 at 36 weeks gestational age. She was brought in by her sister, who is quite agitated and upset, saying “everybody has been ignoring her symptoms for the last 4 weeks.” The patient has just experienced a syncopal episode at home.

Case Summary

A 38-year-old female G2P1 at 36 weeks GA presents with acute on chronic respiratory distress in addition to chronic peripheral edema. She undergoes respiratory fatigue and hypoxia requiring intubation. She then becomes hypotensive which the team discovers is secondary to cardiogenic shock, requiring vasopressor infusion and consultation with Cardiology/ ICU.

Download the case here: Pregnant Cardiomyopathy

ECG for the case found here:

(ECG source: https://lifeinthefastlane.com/ecg-library/dilated-cardiomyopathy/)

 CXR for case found here:

posttestQ2pulmonaryedema

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/postquestions/posttest.html)

Cardiac Ultrasound for the case found here:

ezgif.com-optimize+(6)

(U/S source: http://www.thepocusatlas.com/echo/2hj4yjl0bcpxxokzzzoyip9mnz1ck5)

Lung U/S for the case found here:

Confluent+B+Lines

(U/S source: http://www.thepocusatlas.com/pulmonary/)

RUQ FAST U/S Image found here:

usruqneg

(U/S source: http://sinaiem.us/tutorials/fast/us-ruq-normal/)

OB U/S found here:

(U/S source: https://www.youtube.com/watch?v=SKKnTLqI_VM)

Pediatric SVT

This case is written by Drs. Laura Simone and Olivia Ostrow. They are both Pediatric Emergency Physicians at Toronto’s Sick Kids Hospital.

Why it Matters

SVT is the most common pediatric dysrhythmia that we see in the ED after sinus tachycardia. But sometimes, in very young children and infants, it can be hard to distinguish the two! This case highlights some important features of the management of SVT, including:

  • The need for an ECG when they heart rate is very high
  • The role of vagal maneuvers as a first attempt at cardioversion
  • The dosing of adenosine and electricity for cardioversion of SVT

Clinical Vignette

A 12-month old male is brought into your ED today by his parents because he has been fussy, crying all night and not feeding well today. He had emesis x 1 (non-bilious, non-bloody). At triage, the RN had difficulty recording the heart rate but by auscultation it seemed “quite rapid” and he “feels a bit warm”.

Case Summary

The team has been called to the ED after a 12-month old is brought in with a rapid heart rate. The team will realize the patient is in a stable SVT rhythm, with no response to either vagal maneuvers or adenosine. The patient will then progress to having an unstable SVT. If the SVT is defibrillated (i.e. – shocked without synchronization), the patient will progress to VT arrest. If the SVT is cardioverted, the patient will clinically improve.

Download the case here: Pediatric SVT

Initial ECG for the case found here:

SVT

(ECG source: http://hqmeded-ecg.blogspot.ca/2013/01/heart-rate-of-230-beats-per-minute.html)

Post-Cardioversion ECG for the case found here:

normal-sinus-rhythm (1)

(ECG source: http://lifeinthefastlane.com/ecg-library/sinus-tachycardia/)

VT ECG for the case found here:

VT

(ECG source: https://lifeinthefastlane.com/ecg-library/ventricular-tachycardia/)

 

Palliative Respiratory Case

This case is written by Dr. Alexandra Stefan. Dr. Stefan is an emergency medicine physician and the Postgraduate Site Director for Emergency Medicine at Sunnybrook Health Sciences Centre in Toronto. She is also an assistant professor in the Division of Emergency Medicine at the University of Toronto. Her areas of interest are postgraduate medical education, simulation (has completed the Harvard Centre for Medical Simulation training course) and global health  education (has participated in teaching trips with Toronto Addis Ababa Academic Collaboration).

Why it Matters

Emergency medicine training is often focused on the many interventions we can make when a patient arrives in distress. This case highlights that sometimes, one of the most important interventions is to determine a patient’s goals of care. It specifically highlights:

  • The importance of pain management as a part of end of life care
  • The need to speak clearly and without medical jargon to establish a patient’s wishes
  • That goals of care conversations often happen in the ED through a substitute decision maker, rather than with the patient directly.

Clinical Vignette

“A 72 year old man from home with acute shortness of breath has just been placed in the resuscitation room. He has a history of lung cancer and is on 2L home oxygen. His daughter Cindy called 911 because he has been getting worse since this morning. He just finished a course of antibiotics for presumed pneumonia. He is on hydromorph contin and prochlorperazine. No allergies. Here is his most recent oncology clinic note.”

Case Summary

A 72-year old male with small cell lung cancer and bony metastases presents with acute shortness of breath. Curative treatment has been stopped and palliative care assessment is pending. He is on home oxygen and has come to the ED as his symptoms could not be controlled at home.

The patient initially improves with oxygen and pain control. He is too confused to engage in discussion about advanced directives. No previous advanced directives or level of care have been documented but, Cindy, the patient’s daughter is available to act as decision maker. She will have a number of questions about her father’s care.

The patient’s respiratory status will deteriorate. Cindy will confirm her father’s wish for comfort measures, to be started by the treating team.

Download the case here: Palliative Resp Case

Download the clinic note required for the case here: Med Onc Note

ECG for the case found here:

ecg sob case

(ECG source: http://www.thecrashcart.org/case-2-post-partum-palpitations/)

CXR for the case found here:

pleural effusion

(CXR source: https://radiopaedia.org/cases/pleural-effusion-7)

Cardiac Ultrasound for the case found here:

 

(U/S image courtesy of McMaster PoCUS Subspecialty Training Program.)

Elderly Psychosis and Agitation

This case is written by Drs. Nicole Kester-Green and Jen Riley. Dr. Kester-Greene is a staff physician at Sunnybrook Health Sciences Centre in the Department of Emergency Services and an assistant professor in the Department of Medicine, Division of Emergency Medicine. She has completed a simulation educators training course at Harvard Centre for Medical Simulation and is currently Director of Emergency Medicine Simulation at Sunnybrook. Dr. Riley is a staff emergency physician at St. Michael’s Hospital and assistant professor at the University of Toronto.  Her areas of interest are in simulation and medical technology, with a focus on developing programs and curriculum for trainees and faculty both in medicine and allied health professions.

Why it Matters

Patients who present to the ED with agitation can be very challenging to manage. It is particularly difficult when the patient clearly lacks capacity and is unable to respond appropriately to any simple commands. In these situations, ensuring the safety of both the patient and staff members becomes the primary goal. This case highlights, specifically:

  • That chemical restraint should always be used if physical restraints are to be used
  • The challenges to assessing a patient who is clearly unwell when that patient is not cooperative
  • The role security plays in ensuring a safe patient care experience

A Note on Safety

Pre-briefing is always an important component of simulation. For this case, it is essential that the pre-briefing takes a little extra time so that the safety of everyone involved is reviewed. The case is designed so that physical restraints are only placed once the standardized patient is traded for a mannequin. Regardless, both the standardized patient and the sim participants should be briefed on the use of simulated restraint. It is essential that a safe word like “time out” is pre-determined in case any participants are feeling unsafe at any point in the case. This would immediately halt the case. Similarly, instructors must be watching closely for safety and cut the scenario if they feel anyone may be harmed. We advocate for having security participate in this case as learners. However, briefing security that they should not use the restraints on the standardized patient would also help ensure safety.

Clinical Vignette

The charge nurse comes to you: “There is a 68 year old woman in the seclusion room. She was observed pacing and acting bizarre at the bus stop. EMS managed to talk her into ambulance. On route she told them her neighbour is trying to poison her. Initially, she was calm but now she is starting to get agitated. She doesn’t have any previous psych admissions in the system. We couldn’t get any vital signs.

Case Summary

A 68-year old woman is found at a bus stop exhibiting bizarre behaviour. She is brought to the ED by paramedics. In the ED, she is expressing paranoid delusions. Her agitation escalates and does not respond to verbal de-escalation or an overwhelming show of force. She will require physical and chemical sedation to facilitate the work-up for her new onset psychosis.

Download the case here: Elderly psychosis and agitation

ECG for the case found here:

normal-sinus-rhythm

(ECG source: https://lifeinthefastlane.com/ecg-library/normal-sinus-rhythm/)

Non-Accidental Trauma

This case is written by Dr. Suzan Schneeweiss. She is a staff physician at Sick Kids Hospital in Toronto and is the Director of Education for the Division of Pediatric Emergency Medicine at the University of Toronto.

Why it Matters

The differential diagnosis for any sick neonate is always broad. This case, in particular, addresses the differential diagnosis and management of a seizing neonate. It highlights the following:

  • The need for anti-epileptics in a neonate with seizures in the context of trauma
  • The importance of including a septic work-up and broad antibiotic/antiviral coverage in the management of a seizing neonate
  • The need to consider non-accidental injury

Clinical Vignette

A 1 month-old male is brought into the ED due to poor feeding and lethargy. The baby was apparently well until this morning, when his mom noticed it was difficult to wake and feed him. There has been no fever. The baby vomited once this morning, and is voiding and stooling normally.

The nurse in triage notices abnormal movements and brings the baby in to your team in the resuscitation room.

Case Summary

The team has been called to help in the ED after a 1 month-old male is brought in seizing. The team is expected to manage the seizure, but then will subsequently realize on examination there are concerning signs for non-accidental trauma, specifically head injury. The team will be expected to establish definitive airway management and consult with PICU and local child protection services.

Download the case here: Non-Accidental Trauma

CXR for the case found here:

neonatal pneumonia

(CXR source: https://radiopaedia.org/articles/neonatal-pneumonia)

 

Pediatric Viral Myocarditis

This case is written by Dr. Adam Cheng. Adam Cheng, MD, FRCPC is Associate Professor, Departments of Paediatrics and Emergency Medicine at the Cumming School of Medicine, University of Calgary.  He is also Scientist, Alberta Children’s Hospital Research Institute and Director, KidSIM-ASPIRE Simulation Research Program, Alberta Children’s Hospital.  Adam is passionate about cardiac arrest, resuscitation, simulation-based education and debriefing. The case has been modified by Drs. Dawn Lim, Andrea Somers, and Nadia Farooki for use at the University of Toronto.

Why it Matters

Myocarditis is a presentation that can be challenging to recognize early. It is often mistaken simply for septic shock. This case highlights some important features of the recognition and management of myocarditis, including:

  • The need to re-evaluate the differential in a patient with persistent hypotension
  • The role of bedside tests in aiding the diagnosis (ECG, POCUS, CXR)
  • The importance of re-evaluating and re-assessing a patient and adjusting the differential diagnosis and management accordingly

Clinical Vignette

You are working in a large community ED. The charge nurse tells you: “EMS have just arrived with a 15-year old boy with shortness of breath and chest pain. His O2 sat is low. EMS have administered oxygen and IVF en route. He looks unwell so I put him in a resuscitation room. Can you see him immediately?”

Case Summary

A 15 year-old male with no prior medical history is brought to the ED by his parents for lethargy, shortness of breath and chest pain. He was feeling run down for the past 4 days with URTI symptoms.

His initial presentation looks like sepsis with a secondary bacterial pneumonia. He becomes hypoxic requiring intubation. He develops hypotension that does not respond as expected to fluids and vasopressors, which should prompt more diagnostics from the team.

Further testing reveals cardiomyopathy with reduced EF and acute CHF. He finally stabilizes with inotropes and diuresis.

 

Download the case here: Pediatric Viral Myocarditis

ECG for the case found here:

sinus-tachy-non-specific-ST-changes

(ECG source: https://lifeinthefastlane.com/ecg-library/myocarditis/)

CXR for the case found here:

cardiomegaly CHF

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/postquestions/posttest.html)

Cardiac U/S for the case found here:

Parasternal Long

(U/S source: http://www.thepocusatlas.com/echo/xg2awokhx1zx8q3ndwjju5cu4t1adq)

Lung U/S for the case found here:

B lines

(U/S source: https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical-education/quick-hits/orthopnea-in-a-patient-with-doxorubicin-exposure.php)

Pediatric Difficult Airway

This case is written by Dr. Jonathan Pirie. He is a staff physician in the Division of Pediatric Emergency Medicine and Associate Professor at the University of Toronto. Dr. Pirie is also the Director of Simulation for Pediatric Emergency Medicine and the Simulation Fellowship program. His simulation interests include development of core curricula for postgraduate training programs, in-situ team training, and mastery learning with competency based simulation for trainees and faculty in pediatric technical skills and resuscitation.

Why it Matters

While croup makes stridor a relatively common presentation in the Pediatric ED, today it is quite rare to have a child with stridor who requires definitive airway management. It is exceedingly rare for an Emergency physician to need to proceed to cricothyroidotomy on a child. This case highlights the following:

  • The initial management steps for a child with undifferentiated, severe stridor
  • The need to call for help early
  • The steps required for a needle cricothyroidotomy and the equipment necessary to ventilate a child after this procedure is performed

Clinical Vignette

You are working in the ED, and your team has been called urgently to see a 2-year-old old boy with difficulty breathing. The patient was brought in by his mother, who states he’s had a 2-day history of runny nose. Today he developed a barking cough with fever, and is “breathing with a funny noise.”

Case Summary

The ED team is called to manage a 2-year-old boy in severe respiratory distress with stridor and hypoxia. Initial management steps (humidified O2, nebulized epinephrine and dexamethasone) fail to improve the patient’s respiratory status, and the team must prepare for a difficult intubation. They will encounter difficulties with both bagging and passing the endotracheal tube due to airway edema, which will necessitate an emergency needle cricothyroidotomy.

Download the case here: Pediatric Difficult Airway

Iron Overdose in a Pregnant Patient

This case is written by Dr. Kate Hayman (@hayman_kate) and Dr. Dawn Lim (@curious doc). Dr. Hayman (MD MPH FRCPC) is an emergency physician at University Health Network and an Assistant Professor at the University of Toronto. Her interests are in health equity, advocacy education, and the use of simulation in low-resource settings.

Why it Matters

Iron toxicity is a relatively rare presentation to the ED. Familiarity with its presentation can be vital to recognizing this potentially lethal overdose. This case highlights the following:

  • The presenting features of moderate to severe iron toxicity
  • The fact that prenatal vitamins contain ferrous fumarate
  • When chelation therapy is indicated for an iron overdose

Clinical Vignette

You are working in a large community ED. You are called to a resuscitation room where EMS has just brought in a 29-year woman with altered mental status. Her boyfriend called 9-1-1 when he found her confused this morning. She is 10 weeks pregnant and had some vomiting and diarrhea yesterday. Her boyfriend is in the waiting room.

Case Summary

A 29-year old woman with a history of depression and an early unplanned pregnancy is found at home with decreased level of consciousness. She comes to the ED with EMS and her boyfriend. She remains altered in the resuscitation room and declines despite aggressive resuscitation.

After gathering history from the boyfriend, it seems likely that she has ingested a large quantity of pre-natal vitamins resulting in iron toxicity. This is confirmed on bloodwork and imaging. She will require airway management, hemodynamic support and specific chelation therapy.

Download the case here: Pregnant Iron OD

AXR for the case found here:

Toxicology_Iron_Tablets-936x1024

(AXR source: https://lifeinthefastlane.com/top-ten-foreign-bodies/)

CXR for the case found here:

post-ETT-CXR

(CXR source: http://jetem.org/ettcxr/)

Abdominal U/S showing IUP for the case found here:

IUP

(U/S source: https://radiologykey.com/first-trimester-pregnancy/)

FAST for the case found here:

Untitled

(U/S source: http://www.emergencyultrasoundteaching.com)

Pelvic U/S for the case found here:

Untitled2

(U/S source: http://www.emergencyultrasoundteaching.com)

In Situ Simulation – Part 2: ED in situ simulation for QI at Kelowna General Hospital

This 2 part series was written by Jared Baylis, JoAnne Slinn, and Kevin Clark. 

Jared Baylis (@baylis_jared) is a PGY-4 and chief resident at the Interior Site of UBC’s Emergency Medicine residency program (@KelownaEM). He has an interest in simulation, medical education, and administration/leadership and is currently a simulation fellow through the Centre of Excellence for Simulation Education and Innovation in Vancouver, BC and a MMEd student through Dundee University.

JoAnne Slinn is a Registered Nurse, with a background in emergency nursing, and the simulation nurse educator at the Pritchard Simulation Centre in Kelowna. She recently completed her Masters of Nursing and has CNA certification in emergency nursing.

Kevin Clark (@KClarkEM) is the Site/Program Director for the UBC Emergency Medicine program in Kelowna. He completed a master’s degree in education with a focus on simulation back in the day when high fidelity simulation was new and sim fellowships weren’t yet a thing.

Welcome back to part 2 of our series on in situ simulation for quality improvement! Check out last months’ post for a deeper dive into the literature behind this concept. In this post, we will outline the vision, structure, participants, results, and lessons learned in the implementation of our ED in situ simulation program at Kelowna General Hospital (KGH).  

The Vision

KGH is a tertiary care community hospital serving the interior region of British Columbia.  Our emergency department (ED) sees in excess of 85,000 patient visits per year.  In 2013, we became a University of British Columbia distributed site for training Royal College emergency medicine residents. With this program came a responsibility to increase the academic activities in the department both for education and for team building and quality improvement (QI). Our aim with the program was:

  1.     Improve interprofessional collaboration.
  2.     Improve resuscitation team communication
  3.     Develop resident resuscitation leadership skills.
  4.     Educate emergency department professionals on medical expertise related to resuscitation.
  5.     Identify and select two quality improvement action items that arise within each resuscitation scenario.
  6.     Assess and respond to each QI action item in the interest of better patient care.
  7.     Educate participants and other department staff with regards to each QI action item in an effort to change process and behaviors.

From a departmental QI standpoint, we applied the “SMART” framework; specific, measurable, attainable, realistic, and time based.¹ Our goal, as stated above, was to select two QI action items that came up during the debrief following our simulation. Our nurse educator group follows-up on each of these items and reports back to the local ED network, pharmacy, or the ED manager depending on which is seen as most appropriate for the particular QI issue. This ensures our model remains sustainable over time. Follow up emails are sent out to “close the loop” with attendees and department staff after each session. Learnings from the simulations are also presented to the local ED network to share with smaller sites that do not have simulation opportunities.

The Structure

Each session includes one to two scenarios where a “patient” with a critical illness is resuscitated by the team. Both adult and pediatric cases have been run using high fidelity simulators and a variety of resuscitation topics. The cases are run over a 90-minute time-period once per month immediately prior to our departmental meeting. This encourages attendance and participation. The timing of in situ simulation also coincides with our residency program’s academic day further increasing attendance and participation. The resuscitation/trauma room in the KGH ED is used for these sessions. The program has been well received and was highlighted on the local Global News Channel as a public display of our QI initiative.

ED in situ 1

ED in situ simulation at KGH

The session begins with a pre-brief that includes brief introductions, general objectives, confidentiality, fidelity contract, and an outline for the session. This is followed by an orientation to the simulator, monitors, and equipment in the room. The scenario is then begun with a pre-hospital notification, bedside handover by paramedics, and then emergency department care ending with decision on disposition. The scenario is run in real time to maximize realism in terms of the time it takes to draw up and administer medications etc. This is followed by a debriefing session that takes in feedback from all team members as well as observers. This is led by a staff physician with experience in simulation debriefing. CanMEDS themes such as communication, collaboration, leadership and medical expertise are all discussed.²

Participants and Recruitment

Participants include emergency physicians, residents, nurses, respiratory therapists, pharmacists, paramedics, security, and students from the aforementioned groups. Participants are recruited with an email announcing the session one week prior, sign up lists on the educators’ door, and posters placed in the ambulance bay and paramedic stations. Cases are determined by the EM Residency Director in conjunction with the Simulation Fellow, ED Nurse Educators, and the Simulation Nurse Educator. The cases are distributed to the discipline leads 2-7 days prior to the session in order to prepare students and newer professionals that may be joining.

Our Results

There were a total of 65 participants when the program began in 2015, with an average of 16 participants/session. This grew to 130 total participants and an average of 19 participants/session in 2016. There was a further increase in 2017 to 213 total participants with a session average of 24 participants giving a total of 408 participants since program inception. The distribution of participant disciplines over the duration of the program is below:

Graph 1: ED In Situ Participant Data 2015 – 2017

sim pic

Feedback has been informal, but overwhelmingly positive. The ED nurse educators have found in-situ simulation to be one of the most valuable educational experiences for the department and have advocated for the sessions to be paid education time for the nurses. This has increased buy-in and participation. Paramedics have commented that it is time well spent, that they appreciate seeing what happens to the patient after they hand over care. They also remarked that this type of training will go a long way towards better inter-agency cooperation and understanding.

A variety of QI initiatives have been brought forward from these sessions. This has included better use of existing protocols, finding equipment that is poorly placed or expired, and determining better team-working processes similar to what was described in our literature review. One specific example of our QI initiatives was the development of a simulation case around our pediatric diabetic ketoacidosis protocol (that was still in draft form), running the case using the protocol, and then providing feedback on revisions including clarity on initial fluid replacement orders, additions to the initial blood work orders, and improvements to insulin pump delivery. Further QI initiatives that have resulted from this project are summarized below.

Table 2: QI action items and their resulting actions

CATEGORY ACTION
Team/Communication

1.     Delay in call for help

2.     Team members not speaking up when change in patient condition noticed

3.     Medication order confusion between physician, pharmacy, and nursing

4.     Not all team members hearing report from paramedics

1.     Reinforce calling for help early

2.     Fostering an environment that encourages input from all team members

3.     Reinforce importance of using closed-loop communication with medication orders

4.     Reinforce one paramedic report where everyone stops and listens (unless actively involved in CPR)

Equipment/Resources

1.     Difficulty in looking up medication information in resus. bay

2.     Unsafe needles for use with agitated patients in resus bay

3.     Expired Blakemore tubes in ED

4.     Unsure of PPE needed during potential Carfentanil exposure case

1.     Installed additional computer in resus. bay in order to better access information

2.     Auto-retractable needles made available in resus. bay

3.     New Blakemore tubes ordered

4.     Communicated the provincial Medical Health Officer recommendations for Carfentanil PPE to staff

Knowledge/Task

1.     Lack of knowledge of local use of DOAC antidote

2.     Uncertain of local process for initiating ECMO in ED

3.     Conflict over when to intubate a hemodynamically unstable patient

1.     Reviewed indications/contraindications, ordering information, and administration of Praxbind (idarucizumab)

2.     Reviewed team placement, patient transfer, and initiation of ECMO line in ED

3.     Reinforced resuscitation prior to intubation

PPE – Personal Protective Equipment

DOAC – Direct-Acting Oral Anticoagulants

ECMO – Extracorporeal Membrane Oxygenation

Successes, Lessons Learned, and Suggestions

In this article, we set out to describe our experience with regard to ED based in situ simulation as well as to outline the evidence for in situ simulation as a QI tool (part 1). We hope that this serves as encouragement to those of you who are thinking of getting such a program started at your institution. In reflecting on our process, we would offer these suggestions and lessons learned:

  1. Engage a team. It takes a team that is committed to the process to get this off the ground. Take the evidence to your team, gain support, and then begin your program.
  2. Start out with your goals/aims/objectives in mind so that you know what it is you’re trying to accomplish.
  3. “Buy in” is key. Try to structure your program so that it is convenient and so that attendance and participation is encouraged. For us this meant holding our in situ simulation on academic days for the residency program and immediately preceding our departmental meeting.
  4. Celebrate your successes with everyone involved to build a culture that values in situ simulation and quality improvement.
  5. Bring team members on board who are trained and experienced in simulation as debriefing a multidisciplinary simulation can introduce specific challenges. This is beyond the scope of this article but there are many good resources out there on debriefing including the PEARLS framework.³

We’ll close with the 10 tips that Spurr et al. described in their excellent article on how to get started on in situ simulation in an ED or critical care setting.

  1. Think about your location and equipment    
  2. Engage departmental leaders to support simulation
  3. Agree on your learning objectives for participants and the department
  4. Be a multiprofessional simulation program
  5. Strive for realism
  6. Start simple, then get complex
  7. Ensure everyone knows the rules and feels safe
  8. Link what you find in simulation to your clinical governance system
  9. The debrief is important: be careful, skillful, and safe
  10. Be mindful of real patient safety and perception

We would love to hear from you. If you have any questions or comments please feel free to comment on this post or to reach us by twitter (@baylis_jared, @KClarkEM, @KelownaEM).

References:

  1. Haughey D. Smart Goals [Internet]. [cited Dec 2017]. https://www.projectsmart.co.uk/smart-goals.php
  2. CanMEDS: Better standards, better physicians, better care [Internet]. [cited Dec 2017]. http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e
  3. Eppich W, Cheng A. Promoting excellence and reflective learning in simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simulation in Healthcare. 2015 Apr 1;10(2):106-15.
  4. Spurr J, Gatward J, Joshi N, Carley SD. Top 10 (+ 1) tips to get started with in situ simulation in emergency and critical care departments. Emerg Med J. 2016 Jul 1;33(7):514-6.