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Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 EXT: NEURO: No edema or rashes WNL, MAE X 4, grossly intact LABS: See Appendix A Amylase/Lipase Level Comprehensive Metabolic Panel Arterial Blood Gas Hepatic Panel Basic Metabolic Panel X Lactate/Cortisol Level Cardiac Markers Thyroid Panel Coagulation Profile Toxicology Screen Complete Blood Count (CBC) Urinalysis CBC with differential X Urine HCG IMAGES: See Appendix B 152 Additional Labs: none Angiogram ECG X CT Scan, with contrast MRI CT Scan, without contrast X-Ray X Echocardiogram Ultrasound CONSULTS: Cardiology – Dr. Jones: ECG, if obtained, is read as normal sinus tachycardia. Radiology – Dr. Smith: CXR is normal. Additional Images: none CLINICAL PROGRESSION: History and physical, IV access, and monitor. Patient has decreasing O 2 saturation, increasing fatigue, and increasingly short of breath until nebulized albuterol administered and supplemental O 2 provided. Participants are expected to recognize and treat low O 2 saturation, build a thorough differential diagnosis, order appropriate laboratory studies/images, and determine need for admission. Once participants administer O 2 , bronchodilators, and steroidal medication, case will end. Alternatively, can progress to increased dyspnea with expectation that advanced interventions such as magnesium, heliox, and intubation will be employed. ***If inhaler is used to provide medication, patient cannot take in a dose before needing to take a breath and does not improve. ***Failure to give supplemental O 2 and nebulized medication within the first 10 minutes of the case will result in increasing tachycardia and decreased O 2 saturation, the vitals will read: HR BP Temperature ( o C) O 2 Sats (RA) RR 130 130/75 37.0 o 88% 32 ***If single dose of nebulized β-agonist (albuterol) and/or antimuscarinic (ipratropium) administered alongside supplemental O 2 , shortness of breath and wheezing improve:
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 HR BP Temperature ( o C) O 2 Sats (NRB) RR 120 130/90 37.5 o 98% 18 ***If continual nebulized albuterol, antimuscarinic medication (ipratropium), and steroids (prednisone) administered, blood pressure and respiratory rate normalize. Shortness of breath and wheezing are completely resolved. VI. VII. Instructor Notes A. Tips to keep scenario flowing 1. If students are unsure of pathology, prompting can come in form of a primary care physician calling to check in on his patient. 2. If supplemental O2 is not provided, nurse can verbalize need for supportive care as patient becomes increasingly dyspneic B. Scenario programming 1. Optimal management path: O2/IV/monitor History and physical examination Appropriate lab workup (none needed): CBC, BMP Appropriate imaging (none needed): CXR, ECG Stacked nebulized β-agonist and antimuscarinic Administer corticosteroid (prednisone) 2. Potential complications/errors path(s): Failure to administer O2 Failure to administer medications via nebulizer 3. Program debugging: N/A Debriefing Plan A. Method of debriefing: Group with multimedia teaching materials B. Debriefing materials C. Potential debriefing topics 1. Team dynamics a. Leadership b. Collaboration c. Communication d. Professionalism 2. Didactic material a. Presentation i. A decreased respiratory rate does not always mean the patient is improving b. Pathophysiology c. Etiology i. Exacerbation triggers ii. Differential diagnosis: pneumothorax, CHF exacerbation, pneumonia, pleural effusion, foreign body d. Treatment i. Treatment strategies: short-acting vs. long-acting medications ii. Factors determining whether to admit patient to hospital iii. Chest xray useful in first time wheeze, or apparent infectious symptoms 153
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