November 2010



MedEd Portal/ POGOe

Human Patient Simulation

• Title:

- Wrist Pain

• Target Audience:

- Medical Students, Emergency Medicine Residents

• Learning Objectives:

- Primary

– Recognize wrist fracture

– Recognize ST elevation myocardial infarction

- Secondary

– EKG within ten minutes

– No Aspirin given allergy

– Send patient to the catheterization lab

- Critical Actions Checklist

– Upper Extremity Deformity

– IV (Intravenous Access)

– O2 (oxygen)

– Monitor

– EKG within ten minutes of arrival

– Accucheck

– No Aspirin

– Nitroglycerin

– Heparin

– Plavix

– Splint

– Cardiac Catheterization

• Environment:

- Environment

– Tertiary Care Center

- Manikin Set Up

– Basic Simulation Man

- Props

– EKG showing STEMI

– EKG showing ventrilcular tachycardia

– X-ray showing wrist fracture

– Splinting Material

- Distractors

– The patient becomes very agitated when his wrist is examined.

• Actors: (All roles may be played by residents participating)

- Lead Physician

- Intern

- Nurse

- Patient’s Wife

• Case Narrative:

- Chief Complaint – Wrist Pain

- History –

– Pt is a 68 year male who presents by private vehicle for evaluation of wrist pain. He has a deformity to his wrist and is in significant pain and distress. The patient has a history of severe Parkinson’s dementia. According to his wife, he fell at his house and now has wrist pain.

- Additional history (only given if specifically asked for)

– The patient had an unwitnessed fall in his living room approximately thirty minutes prior to arrival.

– If asked about details of the patient’s fall, his wife will reveal she found him unconscious.

– Despite his baseline Parkinson’s, his wife feels like he is more agitated responsive and irritable.

– He has been vomiting.

– No other history or review of symptoms can be obtained secondary to his condition.

- Past Medical History

– Parkinson’s Dementia

– ***Other Past Medical History only given if specifically asked for:

• Coronary Artery Disease

• Hypertension

• Diabetes

• Hyperlipidemia

- Social History

– The patient lives at home with his wife under the assistance of a daily home health nurse.

- Medications

– Metoprolol, Lisinopril, Namenda, Sinemet, Glipizide, Lantus

- Surgical History

– Cardiac catheterization with a stent five years ago

- Allergies

– Aspirin - Anaphylaxis

- Review of Systems (obtained from patient’s wife)

– Pt has been excessively fatigued and had non-coffee ground emesis twice this am.

– Patient and wife are unable to provide much more history secondary to his dementia

- Physical Exam

– Blood Pressure 172/110, Heart Rate 97, Respiratory Rate 26, Oxygen Saturation 98% on room air, Temperature 36.8

– Elderly appearing male who appears in mild distress and moderate pain. His is sitting up in the stretcher moaning, rocking back and forth, and holding his wrist. There is non-bloody gastric emesis on the bed sheets.

– Head, Eyes, Ears, Nose and Throat – normocephalic, atraumatic, pupils equally responsive and reactive to light and accommodation

– Respiratory – clear to auscultation bilaterally

– Cardiovascular – tachycardic, pulses 2+ in bilateral upper and lower extremities

– Abdomen – soft, non tender, non distended

– Extremities – dinner fork deformity to the right wrist, able to wiggle fingers,

– Neurological – neurologically intact, able to wiggle fingers on right hand, sensation in right hand is intact

– Skin – diaphoretic, no abrasions

- Scenario Branch Points

– The patient is an elderly male who presents to the Emergency Department for evaluation of wrist pain after a fall. He is unable to provide a complete history given his underlying severe Parkinson’s Dementia.

– The resident needs to recognize the patient’s upper extremity deformity and splint appropriately if time allows.

– The resident needs to obtain a thorough history regarding the patient’s fall to trigger a syncope workup.

• Part of the syncope work up will include an EKG and accucheck

• Electrocardiogram (EKG) should be done within ten minutes

– An EKG needs to be obtained within ten minutes or the patient will have a ventricular tachycardia arrest.

• If this occurs the patient will can be successfully defibrillated.

• A subsequent EKG will reveal an anterior ST segment elevation myocardial infarction (STEMI).

– Once the STEMI is recognized, the patient should be treated appropriately

• Oxygen

• No aspirin – pt has anaphylaxis

o The patient’s wife will provide this information only if asked about allergies

• Nitroglycerin

• Heparin

• Plavix

– Cardiology should be consulted and the patient should be immediately taken to the cardiac catheterization lab

• Instructors Notes:

- Tips to Keep the Scenario Flowing

– The Simulation Director should emphasize the patient appears in much more physical distress then should be caused by a wrist fracture.

– Have the patient’s wife stay in the room.

– The patient will not respond to any questions, should only be moaning in pain, and the only way to obtain a history is through the patient’s wife.

– The patient should have another syncopal episode if an EKG is not obtained within five to ten minutes.

– If the patient has ventricular tachycardia arrest, one attempt at cardioversion will be successful.

– Any EKG thereafter should show an STEMI

– The patient should not have an anaphylactic reaction, even if given aspirin

• Notify the resident after the case of the patient’s allergy.

• Encourage the resident to notify the cardiologist that the patient was given aspirin.

– Once the STEMI is recognized the patient should be sent to the cardiac catheterization lab as soon as possible.

- Tips to Direct Actors

– The patient’s wife should remain vague about the fall. It was unwitnessed and she found him unconscious.

- Scenario Steps

– Optimal Management Path

• Recognize wrist fracture

• Obtain thorough history to reveal syncopal episode

• Obtain an EKG within five to ten minutes

• Identify STEMI

• Do not give Aspirin secondary to allergy

• If time permits, splint the forearm prior to patient going to cardiac catheterization lab.

– Potential Complications Path

• Do not recognize that patient is in distress

• Do not obtain history revealing syncopal episode

• Patient has another syncopal episode with ventricular tachycardia

– Potential Errors Path

• Administering Aspirin

• No EKG within ten minutes

- Imaging and Labs

– CBC – within normal limits (wnl)

– Chem 10 – wnl

– Coags – wnl

– CXR – wnl

– Urinalysis - wnl

– Right wrist xray – Colles’ Fracture

– EKG

• anterior STEMI

• Ventricular Tachycardia

• Debriefing Plan:

- Topics to discuss

– Differential diagnosis for syncope/ unwitnessed fall

– Management of STEMI

– Challenges of history taking in setting of dementia/ delirium

– Causes of delirium

• Pilot Testing and Revision:

- Number of Participants – 4

- Anticipated Management Mistakes

• Not recognizing STEMI

• Giving Aspirin

• Not splinting wrist

• Incomplete history taking

- Evaluation form for participants – generic handout

• Authors:

- John B. Seymour, MD. University of North Carolina Department of Emergency Medicine.

- Rochelle Chijioke, MD. University of North Carolina Department of Emergency Medicine.

- Amar Patel, MS. Director of the Center for Innovative Learning at WakeMed Health & Hospitals.

- Graham Snyder, MD. Assistant Professor and Medical Director of the Center for Innovative Learning at WakeMed Health & Hospitals

- Kevin Biese. MD, MAT. University of North Carolina Department of Emergency Medicine, Assistant Professor and Residency Director

- Jan Busby-Whitehead, MD. University of North Carolina Professor & Chief, Division of Geriatric Medicine; Director, Center for Aging and Health.

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