Floundering – “I have never performed this procedure on a real patient and I am unsure what to do.”

• Mannequin• IV equipment• IV fluids• CXR • Oxygen tank• Nasal cannula

• Spinal needle• Betadine• Ultrasound• Medications:

lidocaine

Awareness of Resources – I was able to utilize available resources to learn how to manage a situation I had little experience with doing.

Ideal Emotional Response DURING Case Ideal Emotional Response AFTER Debriefing

EMERGENCY MEDICINE CASE 2: TAMPONADE Developed by Jessica Schmidt, MD

IDEAL CASE FLOW: Specifics less important than flow – Remember goal is to allow frustration

KEY MEDICAL MANAGEMENT REMINDERS

Recognition of PericardialTamponade

Supplies

• Recognize the clinical signs of tamponade

• Initial management with oxygen and IVF

• Overcome lack of familiarity with performing pericardiocentesis

Ideal Medical Objectives

• Allow case to mimic slow pace often found in resource-limited medical environments. Case may take over 30 minutes to complete.

• Allow ample time for participants to overcome obstacles from difficulty in communication, slow sharing of information, resisting prompting in problem solvingas much as possible.

Keys to Reaching Desired Emotional Response

Patient brought into ER with dyspnea on exertion

FIRST STATE

Patient brought intoER with dyspneaon exertion

FIRST STATEBlood pressure initially improves, but then patient decompensates, becomes diaphoretic, BP drops, patient altered

SECOND STATEPatient dramatically improves withstabilization BP and improved mentation

THIRD STATE

Blood pressure continues to decline

SECOND STATEPatient continues to worsen and codes

THIRD STATE

HypotensionNOT recognized

TamponadeNOT recognized

Hypotension recognized,1-2L IVF given

Tamponade recognized,pericardiocentesis performed

with 1L fluid drained

Vital sign abnormalities: possible hypoxemia or respiratory distress with dyspnea on exertion, elevated JVP, muffled heart sounds, clear lung sounds, pulsus paradoxis (decrease in SBP more than 10 points during inspiration), large heart shadow on CXR, pericardial effusion on ultrasound

Effusion does not equatetamponade

Procedural considerations fortamponade drainage:

Tamponade is the presence of effusion WITH shockUnderlying pathologies include: malignancy, uremia, idiopathic, pericarditis/infectious diseases (TB, HIV), lupus/connective tissue diseases, anticoagulation, trauma, and type A aortic dissection(Advanced) Sonographic findings of tamponade: pericardial effusion (size not important), RV collapse in diastole, plethoric IVC, decrease of >25% doppler flow across the mitral valve during inspirationInitial management considerations: Tampondae is a pre-load dependent state and management should start with IVF or even passive leg raise; avoid intubation/positive pressure ventilation because it reduces pre-load

Subxiphoid approach: Best with ultrasound-guidance, use 16 or 18-gauge spinal needle with an attached 60 mL syringe, semi-recumbent patient position at 30-45 degrees, prep with antiseptic, insert needle below xiphoid process at angle 30-45 degrees to skin aiming toward the L shoulder, draw back constantly until fluid is returned, withdrawal as much fluid as possible either with syringe or 3-way stop cock/IV tubing, remove needle Post-pericardiocentesis considerations:Potential complications: pneumothorax, visceral perforation (can consider NGT prior to drainage to decompress stomach), arrhythmia, intracardiac aspiration, fluid re-accumulation

PROCEED TO CASE PRESENTATION, EXPECTED INTERVENTIONS, AND OBSTACLES

EMERGENCY MEDICINE CASE 2: TAMPONADE. Provide information only as it is requested

PROCEED TO EMERGENCY MEDICINE CASE 2 DEBRIEFING SCRIPT

POTENTIAL INTERVENTIONS AND OBSTACLES

STOP CASE WHEN THE FOLLOWING ARE TRUE

Introduction:You are working in an Emergency Ward in India.

CC: Shortness of breath with exertion

HPI: A 24 year old male presents with increased dyspnea on exertion for the past 2 weeks, also with complaints of fevers, sweats and weight loss. He denies chest pain or cough and no history of asthma or respiratory illnesses.

PMH: none FH: none SH: Lives in Delhi, works as day laborer

Meds: none Allergies: none

Pertinent positives on exam:

Gen: Fatigued with dyspnea when walking, speakingin full sentences, thin

HEENT: PERRL, MMM, neck supple, no LAD

RESP: mild tachypnea, no retractions, no wheeze or crackles

CV: muffled heart sounds, tachycardia, elevated JVP

ABD: soft, NT/ND

Neuro: Awake and alert, MAEE

Ext: mild wasting, no edema

Skin: no rashes

Initial Vitals: Weight 54 kg, 37.5 HR 116 BP 85/60RR 22 O2 sat 88% on RA

ExpectedIntervention Obstacle Possible

Solution(s) Outcome(s)

Oxygen saturation improves with 4L NC

BP improves with 1L bolus, but then decreases again and patient becomes diaphoretic

Patient continues to worsen if no intervention for tamponade, no improvement with NRB/IVF

Patient clinical condition improves and BP improves

Find tank in different locationParticipant must turn on tank and apply NC themselves

Must discuss with family need for IVFParticipant must place IV

Ultrasound or clinical exam

Refer to web or manual for instructions; or consult local practioners experienced with the procedure

No wall O2 condenser, must use oxygen tankNo tank in WardNurse unsure how to turn it on

Additional cost for IVNurse unable to place IV

No CXR until tomorrow(if wait for CXR, patient will decompensate)

Never performed procedure before

FIRST STATE: Apply oxygen

SECOND STATE: Administer IVF

THIRD STATE: Diagnose tamponade

FOURTH STATE: Drain pericardial effusion

Participants have encountered obstacles andfound ways towork aroundlimited resources

Participants have identified tamponade

Participants have discussed possible interventions and solutions

Enough time has passed to allow for sense that case takes longer to manage than at home

EMERGENCY MEDICINE 2 DEBRIEFING SCRIPT1

Remember: Goal of debriefing is not to lecture, but to facilitate discussion

1Adapted with permission from Eppich, W., & Cheng, A. (in press). Promoting Excellence And Reflective Learning in Simulation (PEARLS):Development and Rationale for a Blended Approach to Healthcare Simulation Debriefing. Simul Healthc.

Setting the Scene: “We are going to spend the next 20-30 minutes debriefing the case. We are going to focus our attention on the emotions encountered but will also address the management of the case. We also want to focus on how you overcame obstacles often encountered when managing a case like this in a resource-limited environment.”

Reaction: “How did that feel?” Pay attention to cues pointing to overcoming lack of knowledge with ability to use available resources.

Description/Clarification: “Can someone summarize what the case was about from a medical standpoint by taking us through what just happened? I want to make sure we are all on the same page.”

You may need to clarify and keep this moving by asking follow up questions. “What happened next?”

Application/Summary: “Is there anything you learned during the course of this case, that has changed your perspective about your experience abroad?”

End with each learner providing a take-home point from the case

Analysis:“Remember, the goal is to get the participants to discuss how they dealt with their perceptions of different views of death and futility. Be sure to explore these themes.

• “What obstacles did you encounter to providing the care you felt this patient needed?” • “How did this case differ than care the patient would likely receive at your home institution?” • “How might your reaction to the lack of resources or lack of treatment differ from that of the local providers?

How might they view your reactions?” • “Were there parts of the case you wished you would have changed or done differently” • “How did you feel about the final outcome of the case; how do you think the family felt?”

Framework for Formulating Effective Debriefing Questions – Choose one prompt from each column

Observation Point of View Question

I noticed that... I liked that... How do you all see it?

I saw that... I was thinking... What were the team’s priorities at the time?

I heard you say... It seemed to me... How did the team decide that...

RESULTS

CXR