Table 1.
Summary of Simulation Scenarios.
| Scenario name | Chief Complaint | Scenario summary | Key challenges |
|---|---|---|---|
|
| |||
| Brown | Shortness of breath | A 55-year-old man is in PACU after undergoing laparotomy for bowel perforation due to diverticulitis. In PACU he becomes progressively short of breath, hypotensive and tachycardic. Without treatment this progresses to a respiratory rate of 30, desaturation, even with supplemental O2 of 80%, blood pressure to 88/70 and heart rate of 140 with his preexisting atrial fibrillation | Participant must prioritize and manage multiple problems; diagnostic challenges are substantial. This case requires rapid reaction as patient’s condition quickly deteriorates. Sepsis and surgical complications are likely underlying causes; requires coordination with surgical team. Medical management is complex |
| Hines | Hypotension | The patient is a 51-year-old, T6 paraplegic (after motor vehicle accident 5 years ago) with hypertension, diabetes mellitus (type 2), rheumatoid arthritis (steroid dependent) and a long smoking history, who presented for surgery with pain due to a left kidney stone, having been off all medications for 2 days. He is now in the PACU after multiple minimally invasive urologic procedures resulting in stone extraction and stent placements. He has both a nephrostomy tube and Foley in place with hematuria evident). The patient has potential urosepsis and instability in PACU. He becomes progressively somnolent, hypotensive and tachycardic requiring resuscitation and intubation | Participant must evaluate the key elements of the history and surgical events. Several changes in patient’s condition require reassessment. Left shoulder pain may be a distractor. Spinal injury invokes a broad range of abnormal physiological responses that must be evaluated. This case requires the participant to coordinate care and rapidly execute multiple interventions including ventilatory support and aggressively use vasopressors |
| Jonesa | Altered mental status | Previously healthy adult patient who is in the PACU after an uneventful sedation and regional block for a carpal tunnel release. The patient has an unusual emergence – inappropriately progressing to incoherent verbal responses and abnormal motor movements. The anesthesiologist (confederate) who has been taking care of this patient in the PACU is fixated on the belief that the patient has post-anesthesia delirium. When the confederate anesthesiologist tries to reverse the residual anesthetics, the patient gets worse | Participant must manage a colleague (confederate) fixated on an incorrect diagnosis, creating potentially challenging interpersonal dynamics with an unknown peer. The underlying condition, serotonin syndrome, is relatively uncommon and not well-known to many. Participant must change the direction of the treatment strategy despite an insistent colleague (confederate) and broaden the differential diagnosis considered by the team |
| Wilsona | Chest pain | A 47-year-old female with diabetes mellitus (type 2), hypertension, reflux, and anxiety/depression presents for total thyroidectomy for toxic goiter (on methimazole). In pre-op holding during pre-anesthetic evaluation, she becomes progressively more anxious, tachypneic and uncomfortable. This progresses to chest pain, electrocardiogram changes, and hemodynamic instability with nadir at 15 minutes, if untreated, of tachycardia (134), hypotension (78/48), desaturation (82%), and wheezing | Participant must delay or cancel surgery; requires negotiation with surgical colleague (confederate) who is reluctant to delay or cancel. The patient arrives late, increasing time pressure. Participant must recognize an acute myocardial infarction, provide supportive therapy, and coordinate care for transfer to cardiac catheterization lab/Cardiology. Patient’s persistent hyperthyroidism complicates interpretation of symptoms |
PACU refers to Post-Anesthesia Care Unit.
a
Patient is portrayed by an actor (i.e., a standardized patient). For Brown and Jones, the patient is portrayed by a manikin with someone else speaking through a microphone for patient interactions.