Human Patient Simulation

MedEd Portal Human Patient Simulation

 Title:

- Wrist Pain

 Target Audience:

- Medical Students, Emergency Medicine Residents

 Learning Objectives:

- Primary – Recognize wrist fracture – Recognize ST elevation myocardial infarction – Recognize that in elderly patients with ST elevation myocardial infarction, chief complaint is less likely to be chest pain than in younger patients. - Secondary – EKG within ten minutes – No aspirin given allergy – Send patient to the catheterization lab – Identify delirium in setting of background dementia

- Critical Actions Checklist – Identify upper extremity deformity – IV – O2 – Monitor – EKG within ten minutes of arrival – Accucheck – No aspirin – Nitroglycerin – Heparin – Splint – Cardiac catheterization

 Environment:

- Environment – Tertiary Care Center - Manikin Set Up – Basic Simulation Man - Props – EKG showing anterior STEMI – EKG showing ventricular fibrillation – 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 78 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 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, Memantine, Levodopa-carbidopa, Glipizide, insulin glargine (Lantus)

- Surgical History – Cardiac catheterization with a left anterior descending 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 additional history secondary to his dementia

- Physical Exam – Blood Pressure 172/110, Heart Rate 97, Respiratory Rate 26, Oxygen Saturation 98% on room air, 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. He is unable to focus attention for entire conversations. – Head, Eyes, Ears, Nose and Throat – normocephalic, atraumatic, pupils equally responsive and reactive to light and accommodation, no cervical tenderness to palpation – 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 fibrillation 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  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 fibrillation arrest, one attempt at cardioversion will be successful. – Any EKG thereafter should show an anterior 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  Identify delirium  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 fibrillation – Potential Errors Path  Administering aspirin  No EKG within ten minutes  Attributing patient’s acute confusion entirely to his dementia

- 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 Fibrillation

 Debriefing Plan:

- Topics to discuss – Differential Diagnosis for Syncope – Management of STEMI – Aspirin allergy – Identifying delirium in setting of dementia

 Pilot Testing and Revision:

- Number of Participants – 4 - Anticipated Management Mistakes  Not recognizing STEMI  Giving aspirin  Not splinting wrist - Evaluation form for participants – generic handout

 Authors:

- John B. Seymour M.D. University of North Carolina Department of Emergency Medicine, PGY – 3 - Rochelle Chijioke M.D. University of North Carolina Department of Emergency Medicine, PGY - 3 - Kevin Biese M.D. University of North Carolina Department of Emergency Medicine, Associate Professor and Residency Director - Graham Snyder M.D. Wake Med Health and Hospitals Department of Emergency Medicine, Assistant Program Director and Simulation Director - Jan Busby-Whitehead M.D. University of North Carolina Division of Geriatric Medicine/ Institute on Aging, Professor and Chief