COVID-19: Ambulatory Care

February 25, 2020April 5, 2020 / Chris Heyd / 1 Comment

Last week’s case featured a critically ill patient with COVID-19. However, not all patients will present that sick, and not always to a tertiary care centre. In a follow-up case, this patient presents moderately unwell and is a good case to use in an ambulatory care setting such as an urgent care or clinic.

This case was written by Dr. Alex Chorley, a staff emergency physician at Hamilton Health Sciences in Hamilton, Ontario. The case is part of the ongoing in situ simulation project designed to discover and fix or mitigate latent safety threats in the Emergency Department. (To learn more about using in situ simulation for quality improvement, read our previous two-part blog post.)

Why It Matters

Outbreaks of novel respiratory illnesses occur with some regularity (e.g. Severe Acute Respiratory Syndrome (SARS) and Middle-East Respiratory Syndrome (MERS)). With world travel being a modern reality, disease spread can happen quickly requiring careful infection control practices. COVID-19 (aka 2019-nCoV) was first detected in Wuhan, China in December 2019 and has since been declared an outbreak by the WHO (see this link for further information).

This simulation case, designed for a moderately unwell patient presenting to an ambulatory clinic, provides a way to test and improve systems in place for infection control, PPE, and management of exposure to COVID-19 or any high risk communicable respiratory illness.

Clinical Vignette

A 38-year old male has returned from a business trip in Asia last week. Over the last 48 hours, he has developed fever, rigors, myalgias as well as nausea, vomiting and upper respiratory symptoms. He initially was trying to ride it out at home, but is feeling increasingly short of breath and fatigued. He has now presented to your ambulatory care clinic.

Case Summary

This case was designed during the January 2020 COVID-19 outbreak in order to assess and improve team preparedness for safely and effectively caring for a moderately ill coronavirus patient from triage through to EMS transfer out of an ambulatory care setting.

Download the case here: Ambulatory COVID-19

CXR for the case found here:

Courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 31352

COVID-19: Respiratory Failure

February 18, 2020April 5, 2020 / Jared Baylis / 7 Comments

We are interrupting our regular q2weeks cases with this bonus case for use in an in situ simulation setting for testing your emergency department’s response to acutely unwell patient’s with suspected COVID-19. This case was written by Drs. Alia Dharamsi, SooJin Yi and Kate Hayman who are academic staff emergency physicians in Toronto. This case has been used widely at a variety of community and academic EDs in the Greater Toronto Area to facilitate departmental preparedness.

Twitter – @alia_dh + @soojinder + @hayman_kate

Featured image used under creative commons licence by Pete Linforth via Pixabay.

Why It Matters

This well developed simulation case provides a way to test and improve systems in place for infection control, PPE, and management of exposure to COVID-19 or any high risk communicable respiratory illness.

Clinical Vignette

A 35-year-old woman became febrile last night with coryza and woke up acutely short of breath with productive cough, rhinorrhea, and a subjective fever. She presents to triage where she screens positive for potential coronavirus exposure due to fever, respiratory symptoms and a high-risk travel history.

Case Summary

This case was designed during the January 2020 COVID-19 outbreak in order to assess and improve team preparedness for safely and effectively caring for a critically ill coronavirus patient from triage through to intubation.

Download the case here: COVID-19

Find the directions for the props here: Props for COVID-19

Video of the nasal secretion prop:

Geriatric Case 6: Elder Abuse

September 6, 2019 / Chris Heyd / Leave a comment

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 (Simulationpodcast.com).

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:

Elder Abuse Case Download

ECG for the case:

Chest x-ray for the case:

Image courtesy of Dr Usman Bashir, Radiopaedia.org, rID: 18394

Pelvis x-ray for the case:

Image courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 36147

RUQ ultrasound for the case:

U/S source: McMaster PoCUS Subspecialty Training Program

Geriatric Case 4: End of Life Care

June 18, 2019June 17, 2019 / kcaners / Leave a comment

This case is the fourth 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 requiring resuscitation are frequently encountered in the ED. When patients are non-communicative, close family members are regularly required to act as substitute decision makers and represent their family member’s wishes. Engaging and communicating effectively with SDMs in end-of-life and goals-of-care discussions is necessary to provide the most appropriate care for the elderly patient. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

The charge nurse informs you “I just put a very unwell looking patient into resus. She’s from a nursing home facility and the paramedics think she is septic. She’s hypotensive and barely responsive. Honestly, she looks like she might be dying. Her granddaughter is on her way. I don’t think she has a known advanced care directive or code status.”

Case Summary

An 89-year-old patient is brought in to the ED by ambulance from their nursing home. Staff found her unresponsive and hypotensive at morning handover. She had been treated for UTI by her family physician over the last few days. Participants identify severe sepsis and realize that critical care interventions may be inappropriate. This should prompt a goals of care discussion including potential for initiating end-of-life care.

Download the case here:

Geriatric EM EOL Care Download

ECG for the case found here:

ECG source: https://litfl.com/hyperkalaemia-ecg-library/

CXR for the case found here:

CXR source: https://emrems.com/2013/01/30/how-to-you-tell-its-a-right-middle-lobe-infiltrate/

Geriatric Case 1: Delirium

July 17, 2018July 16, 2018 / kcaners / Leave a comment

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

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). 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. 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.

Why it Matters

As our global patient population ages, it is increasingly important that emergency physicians have specialized knowledge in the care of elderly patients. This is particularly true when managing patients with baseline dementia or presenting to the ED with delirium. This case highlights specific challenges in these patients, including:

The need to recognize delirium as symptom of a large array of potential medical illnesses
The importance of a medical work-up in patients with delirium (including blood work, urine, and possible imaging)
The need for health care workers to have a toolbox of de-escalation techniques at their disposal

Clinical Vignette

Patient is sitting on the edge of the ED bed, looking perplexed. She/he is fidgeting and not concentrating on the questions being asked, she/he is staring around the room, looking in his/her bag and picking at the BP cuff and bed sheet. The ED nurse is attempting to do some baseline vital signs on the patient.

Participants asked by ED RN “Could you please go and assess this patient? She/he has just been brought in to the ED by ambulance after a friend found her/him confused at home”

Case Summary

An 81-year-old (wo)man is brought to the ED by her/his friend as she/he is confused and agitated. In the ED, her/his confusion worsens. Initially she/he is fidgety but as the case progresses she/he becomes more agitated and confused. She/he will be fairly uncooperative, moving around and not able to follow many commands. The participants should be looking for a source of infection and evidence of any recent trauma. They are expected to use both non-pharmacological and safe pharmacological options in order to control the situation, ensure patient safety, and facilitate investigations.

Download the case here: Geri EM Delirium

Polytrauma for Team Communication

June 19, 2018 / kcaners / Leave a comment

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)

Palliative Respiratory Case

May 8, 2018May 7, 2018 / kcaners / Leave a comment

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.)

Learner-Consultant Communication

April 24, 2018November 15, 2019 / Jared Baylis / Leave a comment

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.