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)

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.)

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)