SIMulatED
Royal Darwin Hospital Emergency Department
Author: Rebecca Day
Scenario Run Sheet: Orthopaedic Bits and Bobs
Scenario Overview
Estimated SIM Run Time:30mins
Estimated Guided Reflection Time:30mins
Target Group:ED Nurses and Registrars
Brief Summary:26F Physio, MBA. In a collar but denying neck pain. Altered GCS 14.Normal obs. Obviously injured pelvis and left femur #– significant distractors. Reduced sensation and power to bilateral lower limbs below the level of L1. XRays show displaced spiral fracture of femur, open book pelvis, inadequateCSpine lateral. Normal CXR. Unable to get CT at present – CT are 30 mins away. Requires sierra collar, donway splint and TPod device.Orthoreg wants to clear the CSpine because all of the deficits seem to be lower down at L1 level. Requires graded assertiveness.
Learning Objectives
General
Communication with patient and other medical professionals
Scenario Specific
- Primary and secondary trauma surveys
- Cervical Spine Clearance using NEXUS or Canadian CSpine Rules
- Application of a T-Pod device
- Application of a Donway splint
- Graded Assertiveness in conflict situations
Equipment Checklist
Equipment
- TPod/sheet
- Donway splint
- Hard and Sierra collars
- Sand bags
Medications and Fluids
- Analgesics
- Antiemetics
- Cefazolin
- ADT
- IVF
Documents and Forms
- Usual for resus – blood/path/trauma/nursing
Diagnostics Available
- Xrays of chest/pelvis/cspine/femur
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Scenario Preparation/Baseline Parameters
Initial Parameters
P90, RR 24, Sats 98%, Afeb, BP 130/70
Initial Progress
Obs remain same unless painful procedure without ketamine – when develop tachycardia and hypertension
Participants
Staff –
Real patient – haematoma on head, collar on (stiffneck), no pelvic binder, deformed left upper femur
2 doctors, 1 orthoreg (confederate)
Radiographer – prompt than can do shoot through femur if reqd
3 nurses
Instructor Roles
-provideXrays and VBG
Additional Information/Medical History
Demographics: 26F, Physio from Palmerston, riding home late at night, lost control on wet road
HPC – Cant really recall events, remembers leaving friends house, had 1 beer, bike skidded, thinks LOC, cant be sure. Unable to get up afterwards – passer by removed helmet and called for help. Leg, pelvis and back are all very sore.
PMH – 1 x previous MBA – minor, no sig injuries
Proposed Scenario Progression
Arrival with ambos
- M – MBA high speed, full protective gear – leathers and helmet. Skidded and lost control.?LOC
- I – Left femur (open), Pelvic pain and back pain
- S – Normal obs P100, BP 130/70, Sats 99%, RR24
- T – 2x IVC, morphine 10mg, methoxy, hard collar
Primary survey – recognise need for CCollar, open long bone and pelvic fractures likely
Secondary survey – recognise bruises to head, neurological defecits to legs and likely L1 fracture, log roll, FAST
Analgesia/Police Bloods/ADT/Fluclox and Gent for open # (?checketg)
Xrays – Trama series plus shoot through of femur. With plan for a CT when available
Application of TPod/Donway splint/Sierra 2 part collar as delay to CT. Ketamine to facilitate if necessary
Junior Ortho reg appears and want to clear the neck as the defecit seems to be lower at lumber level. Tried to take off collar and assess ROM in neck. – Requires Graded Assertiveness to the point of telling the Ortho Reg to “STOP”.
Debriefing/Guided Reflection Overview
General Opening Questions
How was the scenario? (each team member reflects)
What happened in the scenario – i.e. relay the story to a workmate who wasn’t there
Scenario Specific Questions
What was wrong with the patient?
What medications/investigations may be required?
Where does the patient need to go?
General Wrap-Up Questions
What did you find most beneficial about this scenario
What was the most challenging point in this scenario?
What would you do differently next time?
Case Considerations
- How to clear a CSpine using validated rules
- Which fractures benefit from a TPod device
- How and when to put on a Donway and whether require sedation to facilitate application
- Strategies for graded assertiveness