Chest Pain on the Ward

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

When learners are transitioning to residency, they are often fearful of what feels like a sudden increase in responsibility. A big fear that is common among trainees is the idea that they might be left alone to treat something urgent or beyond their skill level. This case was designed to help alleviate some of those fears. The debriefing should focus on local resources available to learners when they feel alone in the middle of the night. The point of the case is to show them they’re not alone. In particular, this case highlights:

  • How to handle a call from the ward about a patient in distress (get things started while on your way to the ward!)
  • The work-up for an admitted patient with chest pain (and how treatment can change quickly!)
  • The senior-level resources available to learners overnight (ICU outreach, anesthesia, the senior resident, their attending over the phone, etc) and when learners should make certain to call their superiors

A Special Note

To make this case particularly realistic, we recommend using your local charting system to create a patient note that can be given to learners. If you use an EMR, then print out what an admission note would look like. If you use paper charting, then handwrite an admission note for learners to review!

Clinical Vignette

You are the junior medical resident on call overnight covering for a team of patients you do not know. You get a page from a nurse on the ward: “one of my patients is having chest pain…can you come and see him?”

*Note: the first part of this scenario is actually done best over the phone. Have the learner stand outside the room and call them on their cell phone.

Case Summary

The case will begin with a phone call from the bedside nurse for a patient on the ward that the resident on call is covering. The resident will then arrive at the bedside to find a patient complaining of significant chest pain. The patient will be in some respiratory distress due to CHF. The patient’s initial ECG will show new T-wave inversion. The patient will prompt regarding ongoing chest pain and his ECG will evolve to show an anterolateral STEMI. The team is expected to recognize the evolving STEMI and initiate treatment and cath lab activation.

Download the case here: Chest Pain on the Ward

“Old” ECG for the case found here:

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

Initial ECG on the ward found here:

001 Anterior TWI

(ECG source: http://hqmeded-ecg.blogspot.ca/2015/12/lvh-with-anterior-st-elevation-when-is.html)

Repeat ECG on the ward found here:

003 anterolateral STEMI

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

CXR for the case found here:

(CXR source: https://www.med-ed.virginia.edu/courses/rad/cxr/web%20images/into-chf.jpg)

VSA Megacode

This case is written by Dr. Cheryl ffrench, a staff Emergency Physician at the Health Sciences Centre in Winnipeg. She is the Associate Program Director and the Director of Simulation for the University of Manitoba’s FRCP-EM residency program; she is also on the Advisory Board of emsimcases.com.

Why it Matters

Leading a resuscitation is a core skill of an Emergency Physician. More often than not, we know very little about the patient’s history before orchestrating a team of nurses, respiratory technicians, residents and other team members to provide resuscitative care. Assessment of the cardiac rhythm and pulse allows us to start with ACLS algorithms in order to hopefully obtain return of spontaneous circulation (ROSC), initiate post-ROSC care and arrange for the appropriate disposition of the patient This case, which is geared toward junior learners, highlights the following:

  • The importance of resource allocation during a prolonged resuscitation
  • Managing the resuscitation team, ensuring effective communication and recognizing compression fatigue.
  • Providing high quality ACLS and post-ROSC care
  • Recognizing STEMI as the cause of the cardiac arrest and initiating disposition for percutaneous coronary intervention (PCI)

Clinical Vignette

A 54-year-old male police officer presents to the ED with chest pain. He played his normal weekend hockey game about two hours ago. He has been having retrosternal chest pain since the game ended. It improved with rest, but has not resolved completely. It is worse after walking into the department. He now feels dizzy, short of breath, and nauseous.

Case Summary

A 54-year-old male police officer presents to the ED complaining of chest pain for two hours that started after his weekend hockey game. He is feeling dizzy and short of breath upon presentation. He will have a VT arrest as he is placed on the monitor. He will require two shocks and rounds of CPR before he has ROSC. He will then loose his pulse again while the team is trying to initiate post-arrest care; this will happen several times. Finally, the team will maintain ROSC. When an ECG is performed, it is revealed that the patient has a STEMI and the team will need to call for emergent PCI.

Download the case here: VSA Megacode

ECG for the case found here:

anterolateral

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/10/anterolateral.jpg)

Post Intubation-CXR for the case found here:

normal-intubation2

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)