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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