Foundation Simulation Scenario Development
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Foundation Simulation Scenario Development
KSS SimNet Foundation Seminar
4th October 2011
What are the goals of this Workshop?
✤
Foster Collaboration Share scenario ideas Begin the scenario writing process
✤
✤
What IS full immersion simulation?
✤
A starting point for a teaching session The beginning of a conversation An assessment tool for skill* progression An opportunity to identify trainee needs
✤
✤
✤
The three fundamental attributes of simulation .
1
• • •
Realism Realism Realism
1. SL Dawson, JA Kaufman, The Imperative for Medical Simulation. Proceedings of the IEEE; MARCH 1998: VOL. 86, NO. 3.
Building up the picture
✤ ✤ ✤ ✤ ✤ ✤ ✤
✤ ✤
✤
Nurse Patient The Monitor Name Bands Allergy Bands Drug & fluid chart Care pathway forms. To include results and observations. ECG, Blood results etc. The Cas notes Notes. inc. op’ notes and anaesthetic notes Investigation request forms for all eventualities
✤ ✤ ✤ ✤ ✤ ✤
✤ ✤ ✤ ✤
The drugs Blood bottles ABG syringes Cannulae Dressings and casts Tubes and drains e.g. NG tube/ Urinary catheters Observers, controllers and help Airway equipment Crash Trolley Infusions/ drip stands and pressure bags
Other factors
✤
Is it realistic to run in the time we have? How long will it take to ready the next scenario? Back-up plan/ servicing
✤
✤
“The Leprechaun out of the box moment”.
(Dr. J. A. O’Neill. 2010)
✤
How likely is it to happen? Is it realistic that the trainee would encounter the same series of events outside of the sim suite? Is it essential to the scenario?
✤
✤
PATIENT DESCRIPTION NAME: AGE: WEIGHT: HEIGHT: GENDER: HISTORY OF PRESENTING COMPLAINT
SCENARIO SETTING
PATIENT INFORMATION Allergies History Medications
MONITOR STYLE PARAMETERS REQUIRED Primary ECG Secondary ECG Arterial BP SpO2 PAP CO2 CVP NBP ToF N2O O2 Pulse AwRR CO Tperi Tblood ICP AGT
SCENARIO TITLE INTENDED SCENARIO RUNNING TIME INTENDED DEBRIEF TIME ATTENDING GROUP EXPECTED PARTICIPANT COMPETENCIES
COGNITIVE SKILLS
PRACTICAL SKILLS
BRIEF SUMMARY
LEARNING OBJECTIVES
ANTICIPATED SERIES OF EVENTS EVENT LIST CRITICAL EVENT
PATIENT DESCRIPTION NAME: AGE: WEIGHT: HEIGHT: GENDER: Mary GIBBONS 23 years 70kg 168 cm Female
HISTORY OF Lower abdominal pain for few days & then collapsed in PRESENTING COMPLAINT classroom – Brought to A&E by work colleague. Generally unwell for past couple of weeks – tired off your food, nauseous. If asked – On holiday IN Turkey 2 months ago, had bad diarrhoea & met someone. SCENARIO SETTING A&E, nurse present. Patient is initially conversational, but as becomes unwell she becomes less communicative & begins to become drowsy & unresponsive PMH : Pelvic inflammatory disease (2y ago – received antibiotics), Meningitis (aged 8) Gynae Hx (if asked) : Last period 4 weeks ago (unusually short), Sexual Hx (initially deny intercourse for months, if directly asked admit to holiday fling), Oral contraceptive pill (years), No previous pregnancies, Smear 2y ago (normal), No STDs MHx : Micronor (daily @ 6pm) Allergies : NKDA FHx : Mother & Father alive and well Social : Occasional smoker & drinker Bedside monitor
PATIENT INFORMATION Allergies History Medications
MONITOR STYLE PARAMETERS REQUIRED Y Primary ECG Secondary ECG Y Y Arterial BP SpO2 PAP CO2
CVP NBP ToF N2O O2 Y Pulse
AwRR CO Tperi Tblood ICP AGT
SCENARIO TITLE INTENDED SCENARIO RUNNING TIME INTENDED DEBRIEF TIME ATTENDING GROUP
Ruptured Ectopic – SHOCK 20 minutes 40 minutes FY1 EXPECTED PARTICIPANT COMPETENCIES
Foundation programme curriculum : 2.1, 2.2, 2.3, 2.4, 2.6, 3.1, 3.2, 3.3, 3.4, 3.5, 3.8, 15.3, 15.6, 16 COGNITIVE SKILLS History & examination – focused on patient with abdominal pain (including gynaecology history). Correct analgesia administration Differential for RIF pain Recognition and treatment of shock. Management of ruptured ectopic – relevant history, Investigations required, appropriate referral. BRIEF SUMMARY Patient brought to A&E following episode of collapse at school. Has generally been unwell for couple of weeks, but for past two days has had worsening RIF pain. Initially patient talkative & gives good history when prompted. Suffering from severe RIF pain that requires analgesia – though even morphine doesn’t fully resolve the pain. Patient starts to become haemodynamically unstable (tachycardia + hypotension) and requires fluid resuscitation. Doctor needs to determine the cause of the pain + shock and gather necessary information to refer to gynaecology. Patient becomes more unstable requiring further fluid challenge, more venous access, indwelling catheter. Doctor should refer to gynaecology & emphasise the severity of the situation. LEARNING OBJECTIVES History and examination to reach differential diagnosis, including focused history as case develops Management of ruptured ectopic – Investigations + Treatment Management of shock – Determining cause, administering fluid & reassessing How to make succinct and effective referral PRACTICAL SKILLS History including gynaecology focused on presenting symptoms. Abdominal examination in a patient in pain. Administration of a fluid challenge + reassessment and re-administer. Administration of IV analgesia + IV fluids
ANTICIPATED SERIES OF EVENTS EVENT LIST Attend to patient – Begin history & acknowledge the pain they are suffering Administer analgesia to allow comfort + full history & examination Get full monitoring of patient – BP 110/60, HR 98, RR 22, Sats 98% Carry out full history and examination to allow differential diagnosis O/E CVS – HR regular, 98 BPM, HS normal, JVP not visible, CRT <2s, No oedema RESP – Chest clear, Percussion normal GI – Tender ++ in RIF with guarding, Otherwise soft and some referred tenderness to RIF, Bowel sounds present CNS – Normal Other : Calves soft non tender, Heart rate begins to rise on monitor (to ~120-140) BP fallen on monitor (~90/50) - Need to prompt nurse or do themselves Saturations also begin to fall ~92% Administer fluid challenge (500ml – crystalloid/colloid) – ensure large cannula & flowing quickly + Oxygen Hopefully has working diagnosis – Shock secondary to intraabdominal pathology – likely ruptured ectopic. Ensure correct investigations ordered – Bloods (FBC, U&E, G&S/XM, LFT, Clotting), patient kept ready for theatre (NBM, AMPLE history for theatre) Y Y Y Y Y CRITICAL EVENT
HR continues to rise in line with falling BP – Candidate should ask for further Y IV access and run more fluid + consider catheter insertion Collects necessary investigations to make referral to relevant team Urine dip (confirm pregnancy) – Patient unable to pass urine (candidate should consider catheter – either in/out or indwelling) Y
Make succinct/effective referral to gynaecology SPR for further management Y
Foundation Simulation Scenario Development
KSS SimNet Foundation Seminar
4th October 2011
What are the goals of this Workshop?
✤
Foster Collaboration Share scenario ideas Begin the scenario writing process
✤
✤
What IS full immersion simulation?
✤
A starting point for a teaching session The beginning of a conversation An assessment tool for skill* progression An opportunity to identify trainee needs
✤
✤
✤
The three fundamental attributes of simulation .
1
• • •
Realism Realism Realism
1. SL Dawson, JA Kaufman, The Imperative for Medical Simulation. Proceedings of the IEEE; MARCH 1998: VOL. 86, NO. 3.
Building up the picture
✤ ✤ ✤ ✤ ✤ ✤ ✤
✤ ✤
✤
Nurse Patient The Monitor Name Bands Allergy Bands Drug & fluid chart Care pathway forms. To include results and observations. ECG, Blood results etc. The Cas notes Notes. inc. op’ notes and anaesthetic notes Investigation request forms for all eventualities
✤ ✤ ✤ ✤ ✤ ✤
✤ ✤ ✤ ✤
The drugs Blood bottles ABG syringes Cannulae Dressings and casts Tubes and drains e.g. NG tube/ Urinary catheters Observers, controllers and help Airway equipment Crash Trolley Infusions/ drip stands and pressure bags
Other factors
✤
Is it realistic to run in the time we have? How long will it take to ready the next scenario? Back-up plan/ servicing
✤
✤
“The Leprechaun out of the box moment”.
(Dr. J. A. O’Neill. 2010)
✤
How likely is it to happen? Is it realistic that the trainee would encounter the same series of events outside of the sim suite? Is it essential to the scenario?
✤
✤
PATIENT DESCRIPTION NAME: AGE: WEIGHT: HEIGHT: GENDER: HISTORY OF PRESENTING COMPLAINT
SCENARIO SETTING
PATIENT INFORMATION Allergies History Medications
MONITOR STYLE PARAMETERS REQUIRED Primary ECG Secondary ECG Arterial BP SpO2 PAP CO2 CVP NBP ToF N2O O2 Pulse AwRR CO Tperi Tblood ICP AGT
SCENARIO TITLE INTENDED SCENARIO RUNNING TIME INTENDED DEBRIEF TIME ATTENDING GROUP EXPECTED PARTICIPANT COMPETENCIES
COGNITIVE SKILLS
PRACTICAL SKILLS
BRIEF SUMMARY
LEARNING OBJECTIVES
ANTICIPATED SERIES OF EVENTS EVENT LIST CRITICAL EVENT
PATIENT DESCRIPTION NAME: AGE: WEIGHT: HEIGHT: GENDER: Mary GIBBONS 23 years 70kg 168 cm Female
HISTORY OF Lower abdominal pain for few days & then collapsed in PRESENTING COMPLAINT classroom – Brought to A&E by work colleague. Generally unwell for past couple of weeks – tired off your food, nauseous. If asked – On holiday IN Turkey 2 months ago, had bad diarrhoea & met someone. SCENARIO SETTING A&E, nurse present. Patient is initially conversational, but as becomes unwell she becomes less communicative & begins to become drowsy & unresponsive PMH : Pelvic inflammatory disease (2y ago – received antibiotics), Meningitis (aged 8) Gynae Hx (if asked) : Last period 4 weeks ago (unusually short), Sexual Hx (initially deny intercourse for months, if directly asked admit to holiday fling), Oral contraceptive pill (years), No previous pregnancies, Smear 2y ago (normal), No STDs MHx : Micronor (daily @ 6pm) Allergies : NKDA FHx : Mother & Father alive and well Social : Occasional smoker & drinker Bedside monitor
PATIENT INFORMATION Allergies History Medications
MONITOR STYLE PARAMETERS REQUIRED Y Primary ECG Secondary ECG Y Y Arterial BP SpO2 PAP CO2
CVP NBP ToF N2O O2 Y Pulse
AwRR CO Tperi Tblood ICP AGT
SCENARIO TITLE INTENDED SCENARIO RUNNING TIME INTENDED DEBRIEF TIME ATTENDING GROUP
Ruptured Ectopic – SHOCK 20 minutes 40 minutes FY1 EXPECTED PARTICIPANT COMPETENCIES
Foundation programme curriculum : 2.1, 2.2, 2.3, 2.4, 2.6, 3.1, 3.2, 3.3, 3.4, 3.5, 3.8, 15.3, 15.6, 16 COGNITIVE SKILLS History & examination – focused on patient with abdominal pain (including gynaecology history). Correct analgesia administration Differential for RIF pain Recognition and treatment of shock. Management of ruptured ectopic – relevant history, Investigations required, appropriate referral. BRIEF SUMMARY Patient brought to A&E following episode of collapse at school. Has generally been unwell for couple of weeks, but for past two days has had worsening RIF pain. Initially patient talkative & gives good history when prompted. Suffering from severe RIF pain that requires analgesia – though even morphine doesn’t fully resolve the pain. Patient starts to become haemodynamically unstable (tachycardia + hypotension) and requires fluid resuscitation. Doctor needs to determine the cause of the pain + shock and gather necessary information to refer to gynaecology. Patient becomes more unstable requiring further fluid challenge, more venous access, indwelling catheter. Doctor should refer to gynaecology & emphasise the severity of the situation. LEARNING OBJECTIVES History and examination to reach differential diagnosis, including focused history as case develops Management of ruptured ectopic – Investigations + Treatment Management of shock – Determining cause, administering fluid & reassessing How to make succinct and effective referral PRACTICAL SKILLS History including gynaecology focused on presenting symptoms. Abdominal examination in a patient in pain. Administration of a fluid challenge + reassessment and re-administer. Administration of IV analgesia + IV fluids
ANTICIPATED SERIES OF EVENTS EVENT LIST Attend to patient – Begin history & acknowledge the pain they are suffering Administer analgesia to allow comfort + full history & examination Get full monitoring of patient – BP 110/60, HR 98, RR 22, Sats 98% Carry out full history and examination to allow differential diagnosis O/E CVS – HR regular, 98 BPM, HS normal, JVP not visible, CRT <2s, No oedema RESP – Chest clear, Percussion normal GI – Tender ++ in RIF with guarding, Otherwise soft and some referred tenderness to RIF, Bowel sounds present CNS – Normal Other : Calves soft non tender, Heart rate begins to rise on monitor (to ~120-140) BP fallen on monitor (~90/50) - Need to prompt nurse or do themselves Saturations also begin to fall ~92% Administer fluid challenge (500ml – crystalloid/colloid) – ensure large cannula & flowing quickly + Oxygen Hopefully has working diagnosis – Shock secondary to intraabdominal pathology – likely ruptured ectopic. Ensure correct investigations ordered – Bloods (FBC, U&E, G&S/XM, LFT, Clotting), patient kept ready for theatre (NBM, AMPLE history for theatre) Y Y Y Y Y CRITICAL EVENT
HR continues to rise in line with falling BP – Candidate should ask for further Y IV access and run more fluid + consider catheter insertion Collects necessary investigations to make referral to relevant team Urine dip (confirm pregnancy) – Patient unable to pass urine (candidate should consider catheter – either in/out or indwelling) Y
Make succinct/effective referral to gynaecology SPR for further management Y
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