This case is thefourth 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.
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.”
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.
Written by Sonja Wakeling. Edited by Dr. Teresa Chan.
Everything I know about ED management I learned from… A Board Game?
GridlockED is an innovative board game that fosters teamwork, knowledge acquisition and application, and problem-solving skills. Developed by clinician educators and trainees, it was designed to simulate real-life settings in an emergency department within a risk-free learning environment. In the healthcare field, it is impossible to allow junior learners full reign of an emergency department, yet they require some level of experience if they are to be responsible and effective when they are practicing and learning. It is imperative that learners exercise and develop skills in a variety of required domains, such as the Royal College of Physicians and Surgeons of Canada’s CanMEDs qualities; these include communication, collaboration, health leadership, health advocacy, scholarship, and professionalism..(1)
Learners acquire knowledge in a variety of approaches, traditionally through didactic lectures but also through other more interactive methods. There has been an important shift from classic knowledge dissemination to more active participation(2); however, finding novel ways to provide both effective and efficient acquisition assists in training a highly-qualified generation of new physicians. In recent years, there has been a surge of simulation-based learning in medical education, particularly at the level of post-graduate and undergraduate medical training.(3) Multiple studies have shown that simulations are an effective method of education; for example, increasing the learner’s confidence in addition to increasing knowledge retention both short- and long-term.(4)
GridlockED: a serious game for learners
Serious games, which Bergeron defines as an “interactive computer application, with or without signiﬁcant hardware components”, are a form of simulations.(5) Instead of being designed with a set of primary winning objectives, their main objective is for the player to acquire knowledge and skills in a challenging and fun learning environment; in a situation like this, the knowledge is seemingly acquired with little effort.(6) This method of learning has recently taken off in residency education, as evidenced by the systematic review of serious gaming within the surgical field(6); however, there is limited evidence to support their utility given that the expanding use of serious gaming as a relatively new approach to medical education. This is one such area that require intensive and thorough research as a means of advancing effective teaching methods in medical education.
In the context of disaster preparedness, tabletop exercises and simulations have been a key aspect of their planning and preparations.(7)GridlockED is an example of a serious game that employs a tabletop simulation approach, which Agboola an colleagues described as one that “involves key personnel discussing simulated scenarios in an informal setting based on existing operational plans and identifying where those plans need to be reﬁned.”(7) GridlockED can accommodate up to 6 participants, given that it is a co-operative and collaborative style of play, whose purpose is to collaborate and reason through the management of patients during a “standard” 8-hour shift in an emergency department. For those with ample professional experience, this task certainly may not seem difficult; however, as a junior learner it sets a great challenge to efficiently and intelligently manage the flow of patients.
Objectives and templates: GridlockED as a teaching tool
So, what makes GridlockED a valuable teaching tool? This low-stakes learning
environment allows participants the opportunity to discuss various approaches,
make mistakes (and more importantly, to learn from them), and come to
understand how they might prioritize certain patients or tasks in a busy
emergency department. The point is not to acquire knowledge around diseases or
illness management, but rather the skill to lead and collaborate in a mission
to provide effective care (and ultimately “win” the game). The beauty of this
game is that this is all done outside of the department where there are no real
patients, and where entrusted facilitators can help provoke discussion around
challenges, successes, and errors.
In addition to the basic gameplay set-up, learning templates are being developed that focus on themed settings or situations that promote particular clinical lessons. For example, there is one theme that results in a shortage of nursing staff, forcing participants to adjust their gameplay style and therefore clinical management akin to a similar situation in a real emergency department. Another theme places you in a rural emergency department with limited resources including staff and specialists available to assist you. Furthermore, an additional template fills your department with patients, taking the game title GridlockED to a serious level. Each teaching template is led by a facilitator who helps the team delve into the decisions they make and reflect on methods to improve their future management.
As a junior learner myself, I have taken
some key learning points away from each round of GridlockED I have participated in; for example, never forget the bigger picture. The
game allows you to slow down for a moment and view the whole “picture” of the
department. Here, you can keep a watchful eye on both patient flow and volume,
consider the challenges you are currently facing, and what you foresee may
occur. Layer on top of this basic gameplay with various themed learning
templates and you have yourself a robust and effective teaching tool that is
also fun to engage in!
But there are many more valuable learning
points I have taken away from each cycle of gameplay lend themselves to the
management of a real emergency department.
Plan ahead. It is not a good idea to leave your high acuity beds with unstable patients in them, unless you have absolutely no choice. If you cannot care for the next patient who comes in in serious condition because your beds are blocked, you (and that patient) are in trouble. And related to that, strategize to maximize the efficiency in each zone of the department.
Prioritize sick patients. Despite patients expressing concern about wait times, there are instances where it is reasonable and indeed appropriate to delay care of low-acuity patients in favour of those who are in serious condition. If someone is waiting in an emergency department, and given the limitations of the healthcare system, it is often a good sign; that individual is not dying or in critical condition, so it means there are other patients who require more immediate attention. That is not a position anyone wants to be in, so try to wait with patience and gratitude.
Collaborate inter-professionally. There are various roles to be played, including nursing, specialties, and learners. However, each participant playing may have a different role in the real world. Rely on their knowledge and experience, and listen to what they say. The most effective leaders know when to lead and also when to listen.
Speaking of collaboration, do not forget
the limitations of each allied health or specialty role. Recognize when a
professional may be in over their head and help where you can. Only so many
blood vials or imaging results can be completed in a fixed amount of time. Be patient, be mindful, and have reasonable
At the end of the day, do what is best for the patients being
treated. See as many patients as you can, treat as many as you can, and do
your best to save everyone you can. Sometimes you cannot save everyone, but
learn from each experience you have so you improve the situation for the next
time you have a similar scenario.
Now that you know what is at stake… Are you up for the challenge?
GridlockED was developed by staff physicians and medical students at McMaster University in Hamilton, Ontario, Canada. Please visit https://gridlockedgame.com if you would like to learn more or purchase the game. All proceeds for the game go towards fostering further education and scholarly projects at McMaster University.
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
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”
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.
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
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.”
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.
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.
“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.”
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.
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.
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.
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.