Respiratory Pathophysiology Simulation 2011
Jeremy B. Richards M.D. M.A., Emily Hayden M.D., M.H.P.E.
Simulation – clinical cases
Respiratory Pathophysiology Course (second-year medical students)
November, 2011
I. TITLE: Respiratory pathophysiology simulation cases (pneumothorax and pneumonia)
II. TARGET AUDIENCE: Medical students 3 months into second year. (Consider third-year medical students.)
III. LEARNING OBJECTIVES / GOALS
A. Goals:
- Experience and understand the initial medical assessment and initial treatment of patients with respiratory symptoms.
- Differentiate between various pathophysiologic mechanisms and how they cause respiratory symptoms.
B. Objectives: By the end of the one-hour simulation program, the students will be able to:
- Correlate pathophysiologic mechanisms (such as increasing pleural pressure) to the diagnosis and management of pneumothorax.
- Describe pathophysiologic consequences of lower respiratory tract infections (such as V/Q mismatch) and how they contribute to symptoms.
- Describe initial treatment strategies for specific respiratory conditions.
C. Critical actions checklist:
Case 1: Baseline:
1)Elicit H&P
2)Perform exam
3)Identify tachycardia
4)Identify relative hypoxemia
5)Provide supplemental oxygen
6)Identify improvement in oxygen saturation with supplemental oxygen
Case 1: Worsening:
1)Identify worsening tachycardia, hypotension, and hypoxemia
2)Order chest x-ray
3)Perform ABG
4)Consider intubation
5)Identify the most likely diagnosis
6)Consult Surgery and/or needle decompress chest and/or place chest tube
Case 1: Improvement:
1)Discuss whether further interventions need to be pursued (if needle decompression, consider chest tube).
2)Provide pain medication for chest tube.
Case 2: Baseline:
1)Elicit H&P
2)Perform exam
3)Identify hypoxemia
4)Identify tachycardia
5)Order EKG
Case 2: Worsening:
1) Order CXR
2) Order ABG
3) Consider intubation
4) Identify the most likely diagnosis
5) Start antibiotics.
Case 2: Stabilization:
1)Consider chest CT.
2) Call ICU
IV. ENVIRONMENT:
A. LAB SET-UP: Standard simulation room with either a one-way observation mirror through which faculty and staff operating the control panel/laptop with mannequin software can observe participants, or a camera (web-cam) for which the faculty and staff can observe the participants from behind a partition. Faculty and staff may speak “for” the mannequin through a microphone at the control panel which will sound from a speaker in or near the mannequin’s mouth, allowing the mannequin to “answer” participants’ questions. The simulation room itself is set up to resemble a standard Emergency Department bay in the first case, and a standard hospital room in the second case.
B. MANNEQUIN SET-UP: Standard simulation mannequin with the capacity to project multiple different physical exam findings (i.e., wheezing and/or crackles and/or normal exam on pulmonary auscultation.) Faculty and staff can affect the mannequin’s physical exam findings in real-time via the control panel.
C. PROPS:
- Bedside monitor with real-time reporting of vital signs.
If possible, can have the following props, but not necessary for preclinical medical students:
- Code / resuscitation cart stocked with standard code medications and equipment.
- Airway kit with laryngoscopes, endotracheal tubes, oral airways, carbon dioxide detectors.
- Medications: morphine, lorazepam, vasopressors, induction medications for intubation, antibiotics.
D. DISTRACTORS: N/A.
E. LOGISTICS: Students will be completing two sim cases in 1 hour. Each sim case will consist of a 3-5 minute intro (see case stem below), 10-15 minute scenario, and 15 minute debrief.
V. ACTORS / STAFF:
A. Simulation specialist or technician – acts as the “voice” of the mannequin at the control panel., using non-medical terminology and speaking using a vocabulary a lay patient may be expected to use.
B. One sim center faculty member/simulation specialist or technician – plays the role of the bedside nurse in both scenarios. Provides medications and relays test results. He/she will coordinate the simulation environment and assist with ensuring that the students move through the case(s) in a timely fashion and will start the debriefing session.
C. One pulmonary faculty member – provides the brief feedback at the end of the sim session(s) regarding students’ understanding of the underlying pathophysiologic mechanisms and how these mechanisms contributed to their understanding of and approach to the clinical scenario. The pulmonary faculty member should not focus on the specific clinical management of the patients, and should only discuss the clinical management as it relates to the pathophysiology of the case.
VI. CASE 1 SCENARIO and INSTRUCTORS’ NOTES: Case 1 –Pneumothorax; Emergency Department Scenario: Nelson Diaz
A. Case background (given freely to participants): Nelson Diaz is a 21 year old man with no significant past medical history presents to the Emergency Department complaining of shortness of breath that started earlier today. You are Emergency Medicine physicians and are the first health care providers to evaluate this patient. The patient has had his vitals taken and is hooked up to a heart rate and pulse oximetry monitor. His nurse is in the room with you as you evaluate the patient.
B. Background and briefing for facilitators / coordinators (NOT given to participants at any point): This simulation scenario involves a young man presenting with acute dyspnea. The students will evaluate the patient through a standard H&P format. Available ancillary information includes his complete vital signs (students must ask the nurse for them and then can be brought up on the bedside monitor), and the results of pertinent tests. A facilitator will play the role of the nurse and assist the students in moving through the H&P and initial evaluation in a timely fashion. This sim scenario should take 10-15 minutes to complete. Debriefing, with a focus on pathophysiologic mechanisms, will occur following the simulation for 15 minutes.
C. Case content: H&P should be elicited by students asking the patient and/or nurse question and/or requesting specific studies. Study results may be immediately available, delayed, or unable to be performed (i.e., “the MRI scanner is down”) at the discretion of the faculty.
History Physical (must be requested and must be stated in as little medical terminology as possible):
-21yo man with no known past medical history.
-Developed sudden onset shortness of breath while playing softball this afternoon.
-He was running to first base when he had acute shortness of breath and had to stop running.
-He had associated right-sided chest pain that was “sharp” in character.
-Nothing like this has ever happened before to him.
-The chest pain has increased since its onset, but the shortness of breath has gradually worsened.
Medications (must be requested):
-He takes no medications, supplements, OTCs.
Family history:
-Sister has mild asthma. Father has hypertension.
Social History (must be requested):
-He smoked cigarettes briefly from age 15-17, but not since (total ~1 pack-year history).
-He smokes marijuana occasionally, last use was last night.
-No other illicit drugs.
-He drinks 2-3 alcoholic drinks 2-3 nights a week and >5 alcoholic drinks every 1-2 weeks.
Review of Systems (must be requested):
-Neuro: No pertinent positives.
-HEENT: No pertinent positives.
-Cardiovascular: Continued, significant chest pain as above, otherwise no pertinent positives.
-Pulmonary: Dyspnea as above, otherwise no pertinent positives, including no antecedent or post-onset cough, wheezing, hoarseness.
-Renal / hepatic: No pertinent positives.
-Endocrine: No pertinent positives.
-Hematologic: No pertinent positives.
Physical Exam(must be performed—if some findings need to be verbalized due to the limitations of the mannequin, only tell them after the students attempt to perform the physical exam maneuver):
-General: Tall, thin, young man appearing to be his stated age. Sitting up on stretcher, using accessory muscles of respiration, speaking in short (but not one-word) sentences, looks to be in moderate respiratory distress.
-HEENT: Normal.
-Cardiovascular: S1S2 RR / tachycardia, no murmurs or extra heart sounds.
-Pulmonary: Absent breath sounds on the right, good air movement with no wheezing or crackles on the left. (If specifically requested – trachea is perhaps mildly deviated to the left).
-Abdomen: Normal.
-Extremities: Normal.
-Neurologic exam: Normal.
Studies (if requested):
-Labs: Normal.
-Peak-flow: Low-normal (~350L/s).
-Chest x-ray: Right-sided pneumothorax. [Image available in Appendix A]
-EKG: Sinus tachycardia, no ischemic changes.
-Chest CT: Right-sided pneumothorax, no PE, otherwise normal (no image).
D. Case progression: Table on next page –
State / Patient status / Learner actions / Trigger to move to next stateBaseline / Uncomfortable appearing, speaking in short (not one-word) sentences, tachycardic, absent breath sounds at the right apex.
HR 120s
BP 150/80
Sat 95% on RA
Sat 98% on 2L NC / 1)Elicit H&P
2)Perform exam
3)Begin to formulate differential diagnosis and consider studies or treatments
4)If the students are not progressing, the pt’s PMD can call overhead and ask what is occurring with their patient—prompting the students to perform the parts of the H&P they are missing, etc. / H&P completed, or
studies / treatments ordered without performing physical exam, or
10-15 minutes.
Worsening / Progressive dyspnea, speaking in 1-2 word sentences, worsened tachycardia, obvious tracheal deviation.
HR 150s
BP 100/60
Sat 88% (on any FiO2)
If asked for:
ABG = pH 7.42 / PaCO2 37 / PaO2 73 (on any FiO2) / 1)React to clinical worsening – consider CXR (if not already ordered)
2)Perform exam (if not already done)
3)Identify the most likely diagnosis
4)Consult Surgery and/or needle decompress chest and/or place chest tube [may need facilitator prompting for this action]
5)If no procedures are to be performed on the mannequins—a Time-Out can be called to talk through the procedure/anatomical landmarks / Diagnosis identified, and
physical exam performed, and
appropriate treatment determined, or
10-15 minutes.
If diagnosis is not identified during this portion of the scenario, facilitators may need to prompt the students to either perform an exam and/or pursue appropriate studies and/or interpret appropriate studies and/or treat the patient appropriately.
If students fixate on an incorrect diagnosis and pursue a treatment plan that will not address his pneumothorax, go to stage 4.
Improvement / After decompression or chest tube placement, he is much more comfortable, less tachycardic, normotensive, speaking in full sentences, but with pain at the chest tube site.
HR 100, BP 120/80
Sat 97% (on any FiO2) / 1)Discuss whether further interventions need to be pursued.
2)Consider pain medication for chest tube. / Move to case 2.
Wrong diagnosis / wrong treatment / Significant clinical worsening, tachycardia, hypotension, hypoxemia - but the pt will not die (as we do not want the debriefing to focus on how to deal with the death of a patient).
HR 180-200s, BP 70/40
Sat 70% (on any FiO2) / 1)Identify that the patient is worsening and that their diagnosis or treatment is not working.
2)Reassess the situation and consider other assessments / interventions. / Correct diagnosis identified, and
Appropriate treatment determined.
If students remain fixated on the wrong diagnosis, faciliators may need to intervene to help the group consider alternatives.
Go to stage 3 when this stage is complete.
VII. CASE 2 SCENARIO and INSTRUCTORS’ NOTES: Case 2 – Pneumonia; Clinic Scenario: Else Fitz
A. Case background (given freely to participants): A 91 year old woman with a history of hypertension, diabetes, osteoporosis, and moderate dementia was admitted to the hospital after suffering a mechanical fall that resulted in a broken right femur. While in the hospital, she has been undergoing cardiac testing to determine her cardiac risk of proceeding to surgery. You are the physicians on-call during the night and you are called to evaluate the patient at 2AM by the patient’s nurse for decreasing oxygen saturation over the past few hours. The patient has had her vitals taken and is hooked up to a heart rate and pulse oximetry monitor. Her nurse is in the room with you as you evaluate the patient. Your attending physician is at home, but is available by pager should you need more assistance.
B. Background and briefing for facilitators / coordinators (NOT given to participants at any point): This simulation scenario involves a woman with multiple co-morbidities who has developed a new pneumonia (either hospital acquired or aspiration). The students will evaluate the patient through a standard H&P format, although the patient’s dementia will limit the interview portion – this is intentional, both to replicate a real-world occurrence (a patient who cannot provide his or her own history) and for time purposes (to minimize the time spent on the HPI to allow both cases 1 and 2 to be performed in an hour). Available ancillary information includes her hospital course (provided by the nurse), her complete vital signs (students must ask the nurse for them), heart rate / oxygen saturation (on the monitor), and the results of pertinent tests. A facilitator will play the role of the nurse and assist the students in moving through the H&P and initial evaluation in a timely fashion. This sim scenario should take 10-15 minutes to complete. Debriefing, with a focus on pathophysiologic mechanisms, will occur after the simulation and will last 15 minutes.
C. Case content: H&P should be elicited by students asking the patient and/or nurse question and/or requesting specific studies. Study results may be immediately available, delayed, or unable to be performed (i.e., “the MRI scanner is down”) at the discretion of the faculty.
History Physical (must be requested):
-91yo woman with hypertension, diabetes, osteoporosis, moderate dementia, and recent hip fracture.
-Patient is alert and oriented x self and “hospital”.
-She denies all symptoms.
Hospital course (may request from nurse):
-The patient has been in the hospital for two days undergoing cardiac testing.
-She was not on supplemental oxygen on admission, but late this afternoon she desaturated to the low 90%s on RA and was placed on 2L NC.
-Over the last several hours, her oxygen needs have increased and she is now on a 50% FM.
-The nurse has observed the patient coughing this evening, occasionally bringing up purulent, yellow-green sputum.
-The nurse also noted the patient was having trouble eating dinner with frequent coughing and choking while swallowing.
Medications (must be requested):
-HCTZ, amlodipine, atorvastatin, aspirin, calcium / vitamin D, metformin, acetaminophen, pantoprazole, and subcutaneous heparin.
Family history (must be requested):
-Her parents have passed away – the patient does not know the causes.
Social History (must be requested):
-She has no known smoking, alcohol or illicit drug use.
Review of Systems (must be requested; limited by patient’s dementia):
-Neuro: No pertinent positives.
-HEENT: No pertinent positives.
-Cardiovascular: No pertinent positives.
-Pulmonary: No pertinent positives, although as above the nurse has noted a productive cough, possible aspiration, and desaturation.
-Renal / hepatic: No pertinent positives.
-Endocrine: No pertinent positives.
-Hematologic: No pertinent positives.
Physical Exam(must be performed—if some findings need to be verbalized due to the limitations of the mannequin, only tell them after the students perform the physical exam maneuver):
-General: Thin, confused woman appearing her stated age. She is using accessory muscles of respiration and intermittently coughing during the interview / exam. She answers questions in short sentences.
-HEENT: Bitemporal wasting, otherwise normal.
-Cardiovascular: S1S2 RR / tachy, III/VI SEM, no extra heart sounds.
-Pulmonary: Decreased breath sounds at the left base with egophany and tactile fremitus, left mid-lung crackles, no wheezing, adequate air movement bilaterally.
-Abdomen: Normal.
-Extremities: Normal.
-Neurologic exam: Alert but only oriented x self and “hospital”. No focal motor deficits.
Studies (if requested):
-Labs (performed earlier that day): WBC 17.0 (90% polys, 5% bands), Hct 34%, platelets 200. Chem-7 normal.
-Chest x-ray: Left basilar opacity (consistent with pneumonia). [Image available in Appendix B]
-EKG: Sinus tachycardia, no ischemic changes.
-Chest CT: Left basilar consolidation, no PE, otherwise normal (no image).
D. Case progression: Table–
State / Patient status / Learner actions / Trigger to move to next stateBaseline / Uncomfortable appearing, speaking in short sentences, tachycardic, crackles on the right.
HR 120s
BP 120/80
Sat 92% on 50% FM / 1)Elicit H&P
2)Perform exam
3)Begin to formulate differential diagnosis and consider studies or treatments
4)If the students are not progressing on this, the pt’s PMD can call overhead and ask what is occurring with their patient—prompting the students to perform the parts of the H&P they are missing, etc. / H&P completed, or
studies / treatments ordered without performing physical exam, or
10-15 minutes.
Worsening / Progressive dyspnea, speaking in 1-2 word sentences, worsened tachycardia, increased frequency of coughing.
HR 130s
BP 100/60
Sat 84% (on any FiO2)
ABG = pH 7.44 / PaCO2 35 / PaO2 59 (on any FiO2) / 1)React to clinical worsening – consider CXR (if not already ordered)
2)Perform exam (if not already done)
3)Identify the most likely diagnosis
4)Start antibiotics. / Diagnosis identified, and
physical exam performed, and
appropriate treatment determined, or
10-15 minutes.
If diagnosis is not identified during this portion of the scenario, facilitators may need to prompt the students to either perform an exam and/or pursue appropriate studies and/or interpret appropriate studies and/or treat the patient appropriately.
Stabilization / After initiation of antibiotics and administration of IVF, the patient is less tachycardic and slightly more comfortable.
HR 120s
BP 120/80
Sat 93% (on any FiO2) / 1)Discuss whether further interventions need to be pursued.
2)Consider transfer to ICU. / Move to debrief.
VIII. DEBRIEFING PLAN:
A. Method of debriefing: Group debriefing primarily facilitated by the pulmonary faculty member, with an emphasis on underlying pathophysiologic mechanisms and their relationship to the clinical signs and symptoms the patients experienced in each case. Video will not be reviewed. Independent support materials beyond class notes will not be distributed.
B. Questions to facilitate debriefing:
- Case 1 (pneumothorax): Key points include the pathophysiologic consequences of air in the pleural space.
-Why did he desaturate?
-Why did he become tachycardic?
-Why did his blood pressure drop with progressive accumulation of air in the pleural space?
-How did his physical exam findings correlate with his diagnosis of pneumothorax?