Pediatric Airway Obstruction

This case was written by Drs. Rob Woods and Gautam Sinha. Rob is an Associate Professor of Emergency Medicine at the University of Saskatchewan.  He works clinically in Adult & Pediatric EM, as well as doing Transport Medicine with STARS.  He is the FRCPC Residency Program Director as well as the Program Director for the Clinician Educator Diploma Program at the University of Saskatchewan.

Why It Matters

Acute airway obstruction is a time sensitive and anxiety inducing presentation. For most providers this is even more true with pediatric patients. When a patient presents to the emergency department with airway compromise, having a methodical and timely approach can be life saving. This case gives a chance to practice recognition and management of the upper airway obstruction.

Clinical Vignette

An 8-year-old boy (30kg) has been brought to the ED by ambulance. He was eating a sausage about 30 minutes earlier and choked.  He lost consciousness with the ambulance crew and they were unable to visualize or remove the foreign body.  He is peri-arrest on ED arrival with O2 saturations in the 40s. 

Case Summary

This case involves an 8 year-old boy with upper airway obstruction from sausage. When indirect treatment fails, removal with Magill forceps under direct visualization is required. The patient slowly recovers after removal of foreign body but will require admission for monitoring.

Download the case here: Pediatric Airway Obstruction

CXR for the case found here:

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(CXR sourced from authors of case)

 

COVID-19: Respiratory Failure

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

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 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:

ECG for the case found here:

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(ECG Source: https://en.ecgpedia.org/wiki/Sinus_Tachycardia)

CXR for the case found here:

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(CXR Source: https://radiopaedia.org/cases/35985)

POCUS for the case found here:

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(POCUS Source: http://www.thepocusatlas.com/pulmonary)

Resuscitative Hysterotomy

This weeks’ case was written by Dr. Amy Hildreth who is an emergency physician and assistant program director for the EM residency at Naval Medical Centre in San Diego.

Why it Matters

Resuscitative hysterotomy is fortunately a rare procedure, however, as with other high impact, low occurrence procedures in emergency medicine, it can be life saving! Equally as important as the procedure itself are the crisis resource management (CRM) components involved in managing two critically ill patients; the mother and the baby.

This case was designed to highlight the management of a pregnant trauma patient, the procedure of resuscitative hysterotomy, and the CRM principles involved. It is not for the faint of heart!

Clinical Vignette

A 30 y/o female was found unresponsive in an SUV that rolled over after being side swiped on the highway going approximately 70 mph (~110kph). The patient has a large, gravid abdomen and, as she was wheeled into the resuscitation bay, the pulse was lost.

Case Summary

The team receives advance notification from EMS about a 30 year-old female who is visibly pregnant and was in a car accident. Upon arrival to the ED the patient loses pulses and CPR begins. The team must begin ACLS/ATLS and proceed to resuscitative hysterotomy. After delivery they should begin neonatal resuscitation and continue management of the mother.  Early consultation should be made to trauma surgery, NICU, and OB. 

Download the case here: Resuscitative Hysterotomy

Nightmares Case 7: Hyperkalemia

This is the seventh 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

You’ve been called to assess a 67M on the general medical floor. He was admitted 3 days ago for a community acquired pneumonia and is now awaiting discharge home once out-patient services can be put in place. He was noted to be hypokalemic on labs this morning (3.2 mEq/L) and the daytime resident ordered KCl 10mEq in 100cc NS bolus, to be given once. On her initial assessment, the overnight nurse found that he was actually placed on an infusion over the last 10 hours and the patient is now confused and bradycardic.

Case Summary

This case involves the diagnosis and management of hyperkalemia. If not treated appropriately the patient will progress to ventricular fibrillation arrest.

Download here

Nightmares Hyperkalemia

EKG for the Case

ECG-Hyperkalemia-junctional-bradycardia-potassium-8

ECG-Hyperkalemia-sine-wave-serum-potassium-9.9

Source for both ECGs: https://litfl.com/hyperkalaemia-ecg-library/

Nightmares Case 5: Pulmonary Edema

This is the fifth 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

A patient is seen by the emergency team, diagnosed with a hip fracture after he slipped and fell, and admitted by the orthopedics service. His medications have been held and he has been made NPO and started on maintenance fluids in anticipation of an operation tomorrow. He is boarding in the emergency department when he wakes up with shortness of breath and hypoxia secondary pulmonary edema.

Case Summary

This case involves the approach to the patient with acute dyspnea. The patient is tachypneic, hypoxic, and hypertensive. The team should consider multiple possibilities but recognize pulmonary edema as the most likely cause.

The team is expected to appropriately call for help while initiating management. The patient will respond to supplemental oxygen, nitrates, and non-invasive positive pressure ventilation after which the internal medicine team will be consulted.

Download here

Pulmonary Edema

Chest X-ray for the Case

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Reference = https://radiologyassistant.nl/chest/chest-x-ray-heart-failure

EKG for the Case

LBBB ECG.png

Reference = http://hqmeded-ecg.blogspot.com/2012/10/hyperkalemia-in-setting-of-left-bundle.html

Ultrasounds for the Case

Find it HERE.

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.

Download here

Seizure

Getting Serious about GridlockED: Lesson Plans to Teach about Systems Improvement

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.


Case 1 – Best Shift Ever (218 kb)

Case 2 – Rural Hospital (226 kb)

Case 3 – Where have all the nurses gone? (216 kb)

Case 4 – Safety Worries (202kb)

Case 5 – Overwhelming Diagnostic Imaging (222 kb)

Case 6 – The Critical Consultant (182 kb)

Case 7 – Night(mare) Shift (234kb)

Case 8 – Code Gridlock! (210 kb)

Download all cases at once. (1.6 MB)


Lessons learned, future patients saved

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.

  1. 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.
  2. 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.
  3. 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 expectations.

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.


References

  1. Royal College of Physicians and Surgeons of Canada: CanMEDS Framework. http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e. Accessed September 3, 2018.
  2. Allerly LA. Educational games and structured experiences. Med Teach. 2004 Sep;26(6):504-5.
  3. Bradley P. The history of simulation in medical education and possible future directions. Med Educ. 2006 Mar;40(3):254-62.
  4. Behar S, Upperman JS, Ramirez M, Dorey F, Nager A. Training medical staff for pediatric disaster victims: a comparison of different teaching methods. Am J Disaster Med. 2008 Jul-Aug;3(4):189-99.
  5. Bergeron BP. Developing Serious Games. Charles River Media: Hingham, 2006.
  6. Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. Br J Surg. 2012;99:1322-1330.
  7. Agboola F, McCarthy T, Biddinger PD. Impact of emergency preparedness exercise on performance. J Public Health Manag Pract. 2013 Sep-Oct;19 Suppl 2:S77-83.

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:

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

Lung U/S for the case found here:

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

RUQ FAST U/S Image found here:

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(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)