Critical Care: Simulation Frustration!

[Indryd]

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OK guys, so it's not that I think my way of doing things was perfect--I'm leaving in my mistakes for all to see--but what the administrators of the exam said was "right" that pisses me off. Long rant, but read on if you're bored.

64 yo "smoker" (with apparently a mysterious medical past) on a medicine floor s/p biliary stenting for pancreatic mass now with decreased mental status.

You have no other info. The patient will be DEAD in 10 minutes unless you make EXACTLY the right interventions.

First thing we ask for vitals than examine "patient".

38.6 120 24 90/60 95% @ RA

Drowsy, oriented to name only. Will not follow commands but screams loudly when you touch her abdomen. LTCAB, RRR, etc, abd SND diffuse tenderness no guarding/rebound, weak pulses. 22 gauge AC only. Recent chest x-ray is normal.

Ordered 2L NC, two large bore IVs and and a liter of fluids full blast, put on monitor, nurses refuse to do capnometry on the floor...morphine 10 IV for possible splinting (woops).

7.5 minutes left.

Re-examine lungs, nl. Patient coughing hard now and yelling about pain.

Fluids running through 22 g, morphine in.

While "nurses are putting in the IVs", pt new vitals are

130 30 60/30 90% @ 2LNC

Pt now unconscious, breathing, weak carotid pulse.

5 minutes left.

IVs are in, order 2 more bags full blast. 100% non-rebreather. Get airway cart ready ("sorry, we need to call anesthesia to intubate on the floor, they can be here in 5 minutes")

Ask for vasopressin (obviously thinking sepsis here)..."we can't run that through a peripheral" --just do it-- "can't do a pressor drip on the floor" grrr...Fine...bolus 20 phenylephrine

160 (narrow complex) 30 and ronchorous 40/0 O2 unreadable Pulseless...but breathing at 30...

2 minutes.

Access, oxygen, fluids, pressors...ummm...

Hands in pockets.

Patient dead.

Now, I know morphine to a septic patient was not good, but it's not what killed her. And I'm not even going to say I did a good job at my attempted resuscitation....

BUT the administrators come in and give us the third degree about EGDT!!!

WTF?

Where the hell is the magic EGDT algorithm that concerns a patient who goes from talking to you to dead in 10 minutes?

They then go on to explain that successful completion of this simulation required:

empiric abx
central line (fast enough to have it done and pushing things through it before patient crashes at about 4 minutes into the simulation, all this on the general medicine floor, mind you)
abg, cbc, cmp, coags, pan cx, heavy fluids

if we had followed this, pt would have lived and not needed pressors or tube.

because, you see, the abx would have taken effect, the labs would have come back, and we could have dumped a hot-tub full of lactated ringers down the magically appearing central line and saved the patient in just 10 minutes!

ohhhh I'm so bitter.

thanks for listening, SDN!

 

[jbar]

Couple of things:

1: Morphine was a big mistake. Not only was it way too much, it was in a patient with a low BP. Also once the patient crashed after morhpine your first thought should have been narcan. Finally, pain control should not be your top priority in an unstable, hypotensive, tachycardiac, febrile patient.

2: Almost every simulation has a specific goal, to teach you something like "how to put in a central line" "how to call a consultant" "how to manage CHF." It isn't about you playing or showing the attendings how good you are. So the arguement of "I did as good a job as I could, they shouldn't have killed my patient" misses the point. The point of your simulation it seems was to teach you to:

a. Recognize sepsis
b. treat sepsis using early goal directed therapy.

Sim is a bit artifical, time is compressed, people may respond better to therapy than in real life. You aren't allowed to do things like spend 5 minutes intubating if that will distract you from the real issues at hand. But the point isn't if LR would fix your patient. The patient was going to get better if you used EGDT and worse if you didn't.

So either you didn't realize they were septic (which is sounds like you did), you don't know EGDT, or you know it and chose not to follow it.

The attendings were trying to teach you that central line, CVP monitoring, fluid resuscitation and antibiotics come before pressors.

I know it's frustrating, but it's more important that you understand what you did wrong in treating sepsis that feeling like they weren't giving you kudos for your managment.

 

[hothause]

So, you made a few big mistakes on a simulated case. Okay, learn from it. Read about early goal directed therapy. Look up hypotension, the types of shock. Learn about pressors, et cetera. Know that next time in the (for instance) chest pain algorithm you don't want to use morphine in someone who's hypotensive. As jbar so nicely said, the point of simulation isn't to be a rockstar and get totally bent out of shape if something goes wrong. The point is to learn so that when it's a real patient you'll know what to do. And, it's simulation so maybe that patient would have petered out in half an hour. Who knows. They wanted you on your toes and threw you in the ocean prior to having swim lessons (or whatever metaphor you'd prefer).

Trust me, I've been there. Simulation of a tylenol, asa, cocaine overdose who was unresponsive, tachy, and hypertensive. So, I intubate sim man and proceed to put his RR at 12 on the imaginary vent (not good in an acidotic asa OD) who was breathing in the 40s to compensate before then. And, I killed my sim patient after otherwise doing appropriate things (intubating someone who can't protect his airway, using n-acetylcysteine, bicarb, fluids, avoiding beta blockers to treat the cocaine induced hypertension, etc). You learn! Try not to take it personally. Seems much better than learning as an intern overnight on the wards.

 

[SoCuteMD]

Agree, especially with jbar. You had a febrile, tachycardic, hypotensive patient with a tender abdomen. Sepsis or PE were my two initial thoughts.

Usually if you are told that something will take too long in sim, it's a sign that you are going down the wrong pathway.

Time is compressed in sim (I wish our lab had the turnaround time we have in sim!). So it's possible that you will be walked through several hours worth of care and work in a 10-15 minute sim. Enjoy it as the learning opportunity it is, and accept the limitations. Don't get too worked up if a patient dies - that's why it's sim!

 

[Indryd]

Thanks for the tips guys.

I guess my biggest problem was not understanding the whole compressed time concept before the simulation started. I am totally not upset about the mistakes I made. I was irritated because I recognized sepsis, I know EGDT like the back of my hand, but talked myself into putting it off because I knew I had ten minutes and nothing would be back on time/abx would have no effect in 10 minutes, etc.

The previous scenarios for this course were real-time (recognize and treat right main-stem after intubation, recognize and treat pneumothorax in a COPDer) and everything we ordered would "take to long" (including labs, cxr, etc) and we were expected to do things based on exam and monitor.

EGDT is a reflex, of course I know it and know to use it in a suspected sepsis.

But for this one, while I recognized sepsis, the last thing on my mind as the patient's BP plummeted right before my eyes was knowing what their white count was when it gets back from the lab an a half-hour and pushing abx that wouldn't make a lick of difference in resuscitating the patient in the short term.

And I'm sure over the internets it seems like I am way more irate/butt-hurt than I really am.

I'm just venting and will not be quitting medicine over this 🙂

 

[Janedoedoctor]

If it's any comfort to you, they were a bit unreasonable imo.

- From conscious and talking to completely dead in 10 min from sepsis is unlikely. Do you mean that what happened over several hours was compressed into 10 mins or was the fast deterioration in the scenario? If yes, you should have ruled out postprocedural bleeding, ruptured AAA or massive PE.

- In my humble opinion, your biggest mistake was keeping the patient on the medicine floor. Your first intervention should have been to establish good venous acces (which you did), the second transfer to a monitored environment where necessary therapies such as intubation and pressors were available. And where you could have eventually placed that central line after initial stabilisation.

- You're right about the central line. If you have 2 large iv's you can run all the fluids you need. Temporarily giving pressors over a peripheral line is feasible. So the only added value of the central line is CVP monitoring for your EGDT. That's a diagnostic and not a therapeutic intervention so it's not appropriate to do it under such dire cicumstances. Expecting you to do it on a medicine floor on such a patient is 🙄

- Early antibiotic therapy is very important, but not so important that it should be started before pressors/fluids in a crashing pt.

- The iv morphine was not a good idea.

 

[LabMonster]

I agree with Jbar also. I also think there were key points in this scenario that stick out - the first that I saw was a 22g IV. Drop in a femoral line and nix the morphine. Other than that I would ALSO agree on the sim admins being a little hasty on the DEAD button. 😉

 

[alreadylernd]

Couple of points:

I agree the scenario wasn't fair in that setting you up with the 10-minute time peroid already skews you in a direction away from sepsis as you mentioned. Sim is already a contrived situation so deliberately creating additional bias with the time limit makes it even more difficult.

Another thing (though probably not allowed in the sim and probably not available on a med/surg floor) to consider for IV access would be an IO. Any time you don't have access, or extremely limited access, sure a central line is great, but even a femoral can take a while, an IO is in in like 3 seconds. Go for the drill! I've used it in pedi status when it's near impossible to get an IV and my pedi central line ability is somewhat limited.

While a septic patient may not die in front of you in 10 minutes, an elderly, hypotensive patient could absolutely crash before your eyes after giving 10 mg of iv morphine (ok, 64 isn't exactly "elderly" but you get my point). If you need to use analgesia in a situation like this (and I agree with a previous poster that it was in fact not a correct action in this scenario), fentanyl has much better hemodynamic stability. And was I mis-reading? 10 mg is a HUGE starting dose.

By and large, I kind of hated sim - too contrived. I think it's utility is in scenarios you don't see every day - pediatric codes/resus, recognizing need for critical procedures without ancillary testing, or reinforcing teamwork functioning in a hectic situation. But reinforcing bread and butter sepsis? Not nearly as helpful.

 

[LabMonster]

Couple of points:

I agree the scenario wasn't fair in that setting you up with the 10-minute time peroid already skews you in a direction away from sepsis as you mentioned. Sim is already a contrived situation so deliberately creating additional bias with the time limit makes it even more difficult.

Another thing (though probably not allowed in the sim and probably not available on a med/surg floor) to consider for IV access would be an IO. Any time you don't have access, or extremely limited access, sure a central line is great, but even a femoral can take a while, an IO is in in like 3 seconds. Go for the drill! I've used it in pedi status when it's near impossible to get an IV and my pedi central line ability is somewhat limited.

While a septic patient may not die in front of you in 10 minutes, an elderly, hypotensive patient could absolutely crash before your eyes after giving 10 mg of iv morphine (ok, 64 isn't exactly "elderly" but you get my point). If you need to use analgesia in a situation like this (and I agree with a previous poster that it was in fact not a correct action in this scenario), fentanyl has much better hemodynamic stability. And was I mis-reading? 10 mg is a HUGE starting dose.

By and large, I kind of hated sim - too contrived. I think it's utility is in scenarios you don't see every day - pediatric codes/resus, recognizing need for critical procedures without ancillary testing, or reinforcing teamwork functioning in a hectic situation. But reinforcing bread and butter sepsis? Not nearly as helpful.

Good point with the I/O. A senior taught me a decent rule of thumb - in an unstable patient, there is one shot for a GOOD IV, i.e. 18 or better, then it's drill baby drill.

 

[hothause]

Yes, sim can be a bit silly at times. The "no, you can't do that." "No, you can't do that." is just a way to get them to make you go down another path. Kind of like the "what am I thinking?" game. Good luck with the next one!

 

[keeping-it-real]

Seems like the simulation had the intended effect, though, as you are now discussing the case and reviewing it in your mind. Most sim cases are meant to be this way, very difficult so that most people won't do everything correctly. The purpose of this is to really tease out those small portions of knowledge that may be missing and make you work under a stressful environment so that you remember which mistakes were made.

Also, knowledge is a different skill than integration of knowledge into a practical scenario. It's not to say that you know or don't know EGDT, but the point is to get your mind acting in real-time and not just static knowledge. And don't take the hyper-critical feedback too personally; it's setup this way so that you learn from the encounter.

Again, the point of simulation is to highlight several teaching points and test you in a fast-paced practical manner. It's not to point out that a septic patient will die in 10 minutes unless you start EGDT. It's to point out that you need to recognize sepsis early, that EGDT therapy needs to be considered, that you don't give narcotics to a hypotensive patient, etc.. It's to get you considering in your mind how this might actually play out in a real-world scenario. The fact that you're now considering it to the degree you are suggests that the desired effect has been achieved. Don't take it too personally, though...nobody actually died.

 

[GeneralVeers]

I agree with the OP that the "10 minute" thing would be confusing. It would certainly throw me off, even in the face of an obvious diagnosis.

If you told me a patient would die in 10 minutes without intervention, I'd assume an acute, but correctable problem like arrhythmia, hyperkalemia, hypoglycemia, metabolic acidosis, or narcotic overdose. I certainly would not even think of something like Sepsis which takes from hours to days to correct.

BTW if a patient is so badly septic and "going to die in 10 minutes", there's probably not much you could ever do in the way of intervention to have a good outcome.