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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 ***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 102 120/80 37.0 o 85% 27 ***If single dose of nebulized β-agonist (albuterol), antimuscarinic (ipratropium) administered alongside supplemental O 2 , shortness of breath and wheezing improve but patient cannot maintain O 2 saturation on room air: HR BP Temperature ( o C) O 2 Sats (RA) RR 106 120/80 37.0 o 91% (O 2 ) 20 ***If continual nebulized albuterol and antimuscarinic medication (ipratropium) administered along with O 2 therapy, blood pressure and respiratory rate normalize. Shortness of breath and wheezing are completely resolved. For advanced participants, consider continuing scenario to include worsening respiratory decompensation after nebs, requiring PPV vs. intubation. Thus, after nebulizers, vitals read: HR BP Temperature ( o C) O 2 Sats (2L NC) RR 125 140/92 37.0 o 79% (O 2 ) 36 VI. Instructor Notes A. Tips to keep scenario flowing B. If students are unsure of pathology, prompting can come in form of a primary care physician calling to check in on their patient. 1. laboratory studiesIf supplemental O 2 is not provided, nurse can verbalize need for supportive care as patient becomes increasingly dyspneic C. Scenario programming 1. Optimal management path: O 2 /IV/monitor History and physical examination Appropriate lab workup: CBC, BMP, ABG Appropriate imaging: CXR, ECG Continual nebulized β-agonist and antimuscarinic Consider corticosteroid (Prednisone) Consider antibiotics 2. Potential complications/errors path(s): Failure to administer O 2 Failure to administer medications via nebulizer 3. Program debugging: N/A 160
Gilbert Program in Medical Simulation Simulation Casebook Harvard Medical School Draft of the 1 st edition (2011), updated 3/2/12 VII. VIII. Debriefing Plan A. Method of debriefing: Group with multimedia teaching materials B. Debriefing materials: See Appendix C C. Potential debriefing topics 1. Team dynamics i. Leadership ii. Collaboration iii. Communication iv. Professionalism 2. Didactic material i. Presentation ii. Pathophysiology 1. COPD vs. Asthma 2. Chronic bronchitis vs. emphysema 3. CO2 retention (ABG with metabolic compensation) iii. Etiology 1. Disease onset 2. Exacerbation triggers iv. Treatment 1. Reversibility of condition 2. Need to provide antibiotics 3. Factors determining whether to admit patient to hospital 4. COPD management 5. Adjunctive treatments: Noninvasive ventilation Development and Deployment This case, along with it precursors (reference Gordon, below) and variants have been used over several years for a wide range of students, including high school, college, masters/PhD candidates, medical students (preclinical and clinical) and resident trainees. The presentation and progression is tailored to the level of the learner; often the COPD case is paired with the Asthma case to allow students to compare and contrast diagnosis, anatomy, physiology, and management. It is commonly used as part of a “train the trainer” curriculum for faculty development in the use of simulation. IX. Authors and their affiliations Case drafted by the Gilbert Simulation Team with group updates and contributions. Compiled and formatted by Elan Guterman. Reviewed and edited with references by Jeffrey Siegelman, M.D. and Zoë Howard, M.D. 161
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