Debriefing Guide: Case 1

Wheezing secondary to Congestive Heart Failure (CHF)from recent viral myocarditis
—Looks like Asthma

  1. Start with generals:
  2. What went well?
  3. What wasn’t so smooth?
  4. Communication between team members?
  5. What frames did the team use? What assumptions did you start with?
  6. Results? What actions led to those results? What caused those actions?
  7. Help me understand why you…
  8. ‘‘I noticed X. I was concerned about that because Y. I wonder how you saw it?’’
  9. Ask about the information they got from the family/nurse.
  10. Did that help sort things out? What did you learn?
  11. Does the information point to one thing or another?
    Example: Poor feeding, getting tired, when were upper respiratory symptoms, length of these symptoms
  12. Ask about what they thought of the vital signs and physical exam.
  13. Tachycardia, hepatomegaly
  14. What happened when you gave fluids? Albuterol?
  15. Ask about the electrocardiogram, chest radiograph (CXR), labs
  16. Shock
  17. Definition of shock: What is shock?
  18. Symptoms of shock:How do you know this patient was in shock?
  19. Compensated
  20. Definition
  21. Why does the heart rate go up?
  22. Why does the respiratory rate go up?
  23. Uncompensated
  24. Kinds of shock (2 groupings)
  25. Hypovolemic
  26. Septic
  27. Obstructive (pericardial tamponade, tension pneumothorax)
  28. Distributive (anaphylactic, neurogenic)
  29. Cardiogenic
  30. What were clues about what kind of shock this was?
  31. Why does this patient have cardiogenic shock?
  1. What parts of this were confusing?
  2. How might you change your thinking next time?

Debriefing Guide: Case 2

Sepsis secondary to pneumonia—Looks like Diabetic Ketoacidosis (DKA)

  1. Start with generals:
  2. What went well?
  3. What wasn’t so smooth?
  4. Communication between team members?
  5. What frames did the team use? What assumptions did they start with?
  6. Results? What actions led to those results? What caused those actions?
  7. Help me understand why you…
  8. ‘‘I noticed X. I was concerned about that because Y. I wonder how you saw it?’’
  9. Ask about the information they got from the family/nurse.
  10. Did that help sort things out? What did you learn?
  11. Does the information point to one thing or another?
    Examples: Cough, fever, lack of polydipsia/polyuria
  12. Ask about what they thought of the vital signs and physical exam.
  13. Discuss the labs: metabolic acidosis, hyperglycemia, elevated creatinine; urinalysis (no ketones)
  14. Shock
  15. Brief review from case 1 of Definition, Symptoms, and Kinds of shock.
  16. How did you know this wasn’t cardiogenic shock?
  17. How did you know this patient was in shock?
  18. How to treat this shock
  19. Septic shock
  20. Is Systemic Inflammatory Response Syndrome (SIRS) plus infection
  21. Two phases: 1. Early, warm: low systemic vascular resistance (SVR)
    2. Late, cold: High SVR
  22. How does this relate to the labs? What about lactate?
  23. Pneumonia
  24. Diagnosis: Physical exam, then CXR if needed; ±white blood cell count
  25. Most common pathogens in this 6 year old patient: Streptococcus pneumoniae, non-typeable Haemophilus influenza, mycoplasma, (viruses first)
  26. What antibiotic(s) would you choose?
  27. This patient: 3rd generationcephalosporin+vancomycin; ampicillin+vancomycin
  28. Less sick hospitalized patient: start with ampicillin; likely won’t need vancomycin
  29. Outpatient: amoxicillin; can add atypical coverage for school aged/older
  30. Follow-up: How long does it take to see response? 48-96 hours
  31. DKA (if time)
  32. What parts of this looked like DKA? What parts of this are inconsistent with DKA?
  33. What is DKA?How do you treat DKA?
  34. What parts of this were confusing?
  35. How might you change your thinking next time?

Debriefing Guide: Case 3

Neurogenic stridor/Chiari crisis secondary to Ventriculo-peritoneal (VP) shunt malfunction
—Looks like Croup

  1. Start with generals:
  2. What went well?
  3. What wasn’t so smooth?
  4. Communication between team members?
  5. What frames did the team use? What assumptions did you start with?
  6. Results? What actions led to those results? What caused those actions?
  7. Help me understand why you…
  8. ‘‘I noticed X. I was concerned about that because Y. I wonder how you saw it?’’
  9. Ask about the information they got from the family/nurse.
  10. Did that help sort things out? What did you learn?
  11. Now that you know what is going on, what questions might you have asked?
  12. Does the information point to one thing or another?
  13. Ask about what they thought of the vital signs and physical exam.
  14. Point out the abnormal neurological exam findings and the palpable shunt.
  15. Discuss differential diagnosis of biphasic stridor.
  16. Discuss the images: CXR and airway films actually show the shunt (no one sees); computed tomography (CT) scan not subtle
  17. How did it go when you called Neurosurgery?
  18. Neurogenic stridor, Chiari Crisis
  19. Increased intracranial pressure(ICP)
  20. Headache, confusion progress to somnolence; decreased cerebral perfusion pressure
  21. Later—papilledema; Cushing triad (bradycardia, hypertension, irregular respirations)
  22. Cranial nerve dysfunction: III—ptosis, anisocoria; CN VI palsy (Lateral rectus weakness)—saw in this patient
  23. Type II Chiari defect
  24. Children with myelomeningocele have Type II Chiari defect
  25. Can develop Chiari Crisis
  26. Secondary to herniation of medulla and cerebellar tonsils through foramen magnum
  27. Choking, stridor, apnea, vocal cord paralysis, pooling of secretions, spasticity of upper extremities
  28. Chiari crisis is a neurosurgical emergency
  29. Take home point: Children with spina bifida and stridor have increased ICP until you prove it isn’t.
  30. Premature Closure/Diagnostic error/Cognitive biases
  31. Why did you think this was croup?
  32. What things are consistent with croup?
  33. What things are inconsistent with croup? Why do you think you didn’t find/didn’t notice these things?
  34. Discussion:
  35. Why do we take cognitive short cuts?
  36. What situations tend to increase risk of cognitive short cuts?
  37. Schemata creation, reliance on these. Impact of experience.
  38. Two strategies for avoiding diagnostic error (not comprehensive)
  39. Ask yourself, “What doesn’t fit (my diagnosis)?”
    Pay attention to the history and the physical exam.
  40. Ask yourself, “If this isn’t X, what else is it?”
    Come up with at least one alternative diagnosis for every patient you see, and then prove to yourself that it isn’t that. Almost always, you can do this with history and exam alone. In this case, “If this isn’t croup, what else could it be?” That opens up a realm of new possibilities wherein you’re more likely to at least consider the correct diagnosis.

Debriefing Guide: Case 4

Perforated retrocecal appendicitis—Looks like pneumonia

  1. Start with generals:
  2. What went well?
  3. What wasn’t so smooth?
  4. Communication between team members?
  5. What frames did the team use? What assumptions did you start with?
  6. Results? What actions led to those results? What caused those actions?
  7. Help me understand why you…
  8. ‘‘I noticed X. I was concerned about that because Y. I wonder how you saw it?’’
  9. Ask about the information they got from the family/nurse.
  10. Did that help sort things out? What did you learn?
  11. Now that you know what is going on, what questions might you have asked?
  12. Does the information point to one thing or another?
  13. Ask about what they thought of the vital signs and physical exam. Especially, the abdominal exam: decreased bowel sounds, diffuse tenderness, guarding, rebound tenderness, positive psoas sign, positive heal tap; rectal exam
  14. Discuss the images and the labs. Why are their white blood cells in the urine?
  15. Appendicitis
  16. Signs/Symptoms
  17. Abdominal pain is primary symptom. Vague, periumbilical, then to right lower quadrant
  18. Diarrhea and urinary symptoms common, particularly if perforated
  19. If diagnosis is delayed >36-48h, good chance of perforation
  20. Perforation can lead to peritonitis, rapidly developing toxicity, signs of sepsis
  21. If retrocecal, evolves more slowly. Pain lateral. More likely to rupture.
  22. Evaluation/Treatment
  23. Imaging—CT best
  24. Morphine does not change diagnostic accuracy or interfere with surgical decision-making (Green, Bulloch, Kabani, Hancock, & Tenenbein, 2005)
  25. Treat SIRS/Sepsis (IV fluid bolus, oxygen, antibiotics)
  26. Call surgery, though if perforated, unlikely to operate
  27. Premature Closure/Diagnostic error/Cognitive biases
  28. Did you think this was pneumonia? Why?
  29. What things are consistent with pneumonia?
  30. What things are inconsistent with pneumonia? Why do you think you didn’t find/didn’t notice these things?
  31. Discussion:
  32. Why do we take cognitive short cuts?
  33. What situations tend to increase risk of cognitive short cuts?
  34. Schemata creation, reliance on these. Impact of experience.
  35. Two strategies for avoiding diagnostic error (not comprehensive)
  36. Ask yourself, “What doesn’t fit (my diagnosis)?”
    Pay attention to the history and the physical exam.
  37. Ask yourself, “If this isn’t X, what else is it?”
    Come up with at least one alternative diagnosis for every patient you see, and then prove to yourself that it isn’t that. Almost always, you can do this with history and exam alone. In this case, “If this isn’t pneumonia, what else could it be?” Likely something in the abdomen—now appendicitis makes more sense.