ideal emotional response during case ideal …expected intervention obstacle possible solution(s)...
Post on 12-Apr-2020
1 Views
Preview:
TRANSCRIPT
Futility – “I thought I was helping the patient, but I am making them worse. The resources to save this patient are not available here.”
• Adult mannequin• IV/IO• IV fluids• Oxygen nasal cannula• ETT
• CBC w or wo diff, blood smear• Blood (family members must
donate)• Medications: morphine, para-
cetamol, ketamine, ceftriaxone
Acknowledgement – Treating chronic problems and malignancy is a high-resource endeavor. Allowing a patient to die with comfort and dignity is part of providing care as well.
Ideal Emotional Response DURING Case Ideal Emotional Response AFTER Debriefing
EMERGENY MEDICINE 3: AML Developed by Jessica Schmidt, MD
IDEAL CASE FLOW: Specifics less important than flow – Remember goal is to allow frustration
KEY MEDICAL MANAGEMENT REMINDERS
Indications for emergentblood transfusion
Supplies
• Recognize the presentation of chronic symptomatic anemia
• Understand indications and potential complications of transfusion
• Recognize end of life and provide comfort
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
• Assess ABCs
• Determine acute or chronic anemia
• Physical exam findings in chronic anemia may include: conjunctival pallor, delayed cap refill, splenomegaly
• Physical exam findings in acute anemia may include: signs of trauma, melena or hematemesis, petechiae, active hemorrhage
• In chronic anemia, transfusion threshold is below Hb of 6-7, but should correlate with patient’s symptomology
• 1 unit prbc (300cc) should increase Hb by 1 g/dL
• Whole blood has high rates of hemolytic transfusion reaction, febrile reaction and even anaphylaxis
Keys to palliation
• Palliative care is defined by the WHO as “improvement in quality of life and relief of suffering for patients with incurable disease”
• Lack of understanding of palliative treatment and lack of availability of opiates severely restrict palliative options in most LMICs
• When providing palliative care, it is important to emphasize communication with the patient, their family and the entire health care team
PROCEED TO CASE PRESENTATION, EXPECTED INTERVENTIONS, AND OBSTACLES
Patient brought into ER with weakness
FIRST STATE
Patient brought into ER with weakness
FIRST STATEPatient continues todeteriorate, givenmorphine
SECOND STATEPatient dies in comfort
THIRD STATE
Patient initially improvesbut then deteriorates
SECOND STATEPatient codes, resuscitative measuresare futile
THIRD STATE
Severe anemia recognized,opt to transfuse patient
Patient withincreased distress
Severe anemia recognized,but palliation prefered
Patient withdecreased distress
EMERGENY MEDICINE 3: AML. Provide information only as it is requested
PROCEED TO AML DEBRIEFING SCRIPT
POTENTIAL INTERVENTIONS AND OBSTACLES
STOP CASE WHEN THE FOLLOWING ARE TRUE
CC: Fatigue
HPI: A 17 year old male patient in Kigali, Rwanda presents with ongoing fatigue for several weeks. No fevers, no rashes, no diarrhea.
PMH: None
FH: No issues
SH: Lives w/ parents and 4 siblings, subsistence farmers in rural village, traveled 2 days to reach referral hospital
Medications: None
Allergies: None
Pertinent Positives on Exam (assume normal if not noted)
GEN: Fatigued, small for stated age
HEENT: Pale conjunctiva, PERRL
RESP: Mild tachypnea, clear lungs with no crackles, no retractions
CV: Tachycardic, 2/6 flow murmur, warm extremities
ABD: Soft, no masses, mild splenomegaly
NEURO: Awake and alert but somewhat slow to answer
EXT: No edema
SKIN: Pale, scattered petechiae
Participants have encountered obstacles andfound ways towork aroundlimited resources
Participants have identified thattransfusion made patient worse and have explored palliative options
Participants have recognized that no treatment options for likely disease state are available
Enough time has passed to allow for sense that case takes longer to manage than at home
Initial Vitals: (ONLY GIVE WHAT IS ASKED FOR): Wt – 70 kg T 38.5 HR 134 RR 24 BP 94/60 O2 88% on RA
ExpectedIntervention Obstacle Possible
Solution(s) Outcome(s)
No labs after 5 pm
No blood bank
Only nasal cannula (no NRB, no BiPAP), no diuretics
Bone marrow biopsy very expensive, only one doctor in town can do it, will not be available until next week,no Hematologist in Rwanda, no treatment for leukemia available in Rwanda
Discuss in person w lab tech or clinically diagnose
Have family donate blood or ask family to collect blood from local blood bank in town
Intubate or allow for comfort measures
Assume diagnosis basedon smear or treat symptom-atically or allow for comfort measures; transfer to Kenya for cancer treatment (expensive)
Very low Hb, blasts/ determine need for transfusion
Initial improvement in patient status
If intubated, stabilized;if comfort measures, patient dies
1. Obtain cbc
2. Transfuse blood
3. Manage respiratory distress after transfusion
4. Work up for anemia
EMERGENCY MEDICINE 3 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...
AML Case Blood Smear Smear: no schistocytes, no parasites, + blasts
top related