Failure: I thought I knew how to make this patient better but I am making them worse. What is different about this patient in this environment?
• Mannequin
• IV equipment
• IV fluids
• BP cuff, thermometer
• Nurse
• Ultrasound machine
• Antibiotics
• Glucose monitor
Adjustment/humility: I learned that having false assumptions that patients will always be physiologically the same as those I am used to, can at times be harmful.
Ideal Emotional Response DURING Case Ideal Emotional Response AFTER Debriefing
Developed by Laurel Guthrie, MD and Jukes P. Namm, MD
IDEAL CASE FLOW: Specifics less important than flow – Remember goal is to allow frustration
KEY MEDICAL MANAGEMENT REMINDERS
Differential forRLQ pain
Management ofacute appendicitis
Supplies• Recognize and clinically diagnose acute appendicitis• Appropriately manage acute appendicitis• Identify postoperative nausea and vomiting• Develop differential for patient’s symptoms• Appropriately manage malaria
Ideal Medical Objectives
Presentation with acute appendicitis
FIRST STATEImprove
SECOND STATE
Give fluids, abx,take to OR
Fevers, nausea, vomiting, headache
THIRD STATEImprovement with administration of quinine or other antimalarials
FOURTH STATE
Think ofdifferential
Monitor for standardpostop recovery
• Clinical exam• Ultrasound• Open appendectomy• Abx: broad spectrum• Remember parasites can cause appendicitis
Clinical signs/symptomsof malaria
• Rigors• Recurrent cyclic fevers• Headache• Myalgias, diarrhea, mild jaundice, cough, vomiting• Hypoglycemia
Management of malaria
• Consult national guidelines• Treat hypoglycemia• Hydrate patient• Transfuse to keep Hgb >5• Consider abx• Give oral meds if tolerated: - Chlorquine +/- primaquine - Artimesinin-based combination therapy (artesunate) - Quinine• Give IV medications if PO not tolerated• Monitor for severe malaria, signs of end organ dysfunction
PROCEED TO CASE PRESENTATION, EXPECTED INTERVENTIONS, AND OBSTACLES
SURGERY CASE 5: ACUTE APPENDICITIS
• 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
SURGERY CASE 5: Provide information only as it is requested
PROCEED TO SURGERY CASE 5 DEBRIEFING SCRIPT
POTENTIAL INTERVENTIONS AND OBSTACLES
STOP CASE WHEN THE FOLLOWING ARE TRUE
Presentation: You are called to the casualty ward to see a 15 year old male with abdominal pain and nausea.
CC: Abdominal pain and nausea
HPI: This is a 15 year old male with worsening abdominal pain and nausea for the past 24 hours.
PMH: unknown
FH: none
Social: In school, lives in a village compound with 12 other family members
Meds: none
All: none
Vitals: T 38.3 C HR 102 R 21 BP 108/84 O2 98%GEN: Awake and alert, in mild distress
HEENT: Spontaneous eye opening, dry mouth
Resp: Mild tachypnea, breath sounds presentbilaterally
CV: Mild tachycardia, no murmurs or arrhythmias
Abd: Tender to palpation of right lower quadrantwith rebound and focal guarding.
Neuro: Oriented x3, follows commands
Ext: Thin, warm, well-perfused
Residents have encountered obstacles and found ways to work around them
Patient has undergone appendectomy and malaria has been appropriately diagnosed and treated
Enough time has passed to allow for the sense that case takes longer to manage than at home
ExpectedIntervention Obstacle Possible
Solution(s) Outcome(s)
KUB shows no free air,no dilated bowel loops
Get KUB –will take timeGo directly to OR
No CT, ultrasound is brokenUltrasound or CT
Improved mentation after fluids, improved blood pressure
Intermittent bolusesNo pump to run fluidsFluid resuscitation
Delay (?POCT machine broken), Hgb low normal, WBC 20
Call tech from homeOnly POCT hgb available; have to call lab technician at home 15 min walk away in order to obtain CBC
Check labs
CBC shows anemiaGet CXR, KUBNo CT, only dipstick for UA, CBCIdentify postoperative fever,get labs, KUB, ?CT scan, UA
Positive for P. falciparum, improves after tx with quinine or other antimalarial
Look at peripheral smear under microscope, treat empirically
No malaria quick test availableTest for malaria
References:
Oxford Handbook of Tropical Medicine, Fourth Edition (2014). pp. 34-67, 308-309. Sabiston Textbook of Surgery, Twentieth Edition (2017). “The Appendix”, pp. 1296-1311.
SURGERY CASE 5 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: “What aspects of the case do you think you managed well?” “Were there aspects you’d wish to manage differently the next time?” “What was different about this case management or flow than what you are used to?” “How might you see yourself reacting to those changes abroad? How might your reactions be perceived by the local medical providers?” “What obstacles did you encounter to providing the care that you felt the child needed?” “How did you overcome those obstacles?”
Review the individual obstacles on Page 2 of the case and the possible solutions. Address WHO recommendations for diagnosis and management of malaria.
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...
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