Table 2. Background case information and expected actions for the chest tube insertion scenario.

ER, emergency room; HR, heart rate; BP, blood pressure; RR, respiratory rate; SaO₂, oxygen saturation rate; HEENT, head, eyes, ears, nose, and throat; ABCDE, Airway, Breathing, Circulation, Disability, Exposure/Examination; IV, intravenous

Pre-scenario
You are working in the ER when a 35-year-old male presents to your hospital after striking a moose on the main highway. Paramedics say the truck was found upside down in the ditch, and the patient had been ejected from the vehicle. He has multiple injuries and is experiencing shortness of breath despite needle thoracostomy conducted by paramedics.
History (Hx)
Allergies	None
Medications	None
Past Medical Hx	None
Physical Exam
Initial Vitals	HR: 120 bpm / BP: 100/70 mmHg / RR: 32 / SaO2: 93%
General	Pale and diaphoretic with significant bruising on the left chest wall, and signs of respiratory distress. The patient is alert, in pain, and having difficulty speaking.
HEENT	Opens eyes in response to voice, disoriented, obeys commands
Chest	Heart sounds normal, breath sounds absent on the left. Percussion note is hyper-resonant on the left.
Abdomen	Soft, non-tender
Extremities	Open femur shaft fracture ***for increased difficulty variant of the case (learners = doctors or residents)
Case Progression:
General Assessment	Vital signs and clinical diagnosis		Expected Action
Initial assessment 1
Runs trauma code using the ABCDE approach	Airway (A) - Patent and protected, trachea deviated to right; Breathing (B) - RR 32, respiratory distress, absent breath sounds and increased tympany on left; Circulation (C) - BP 100/70, HR 120, SaO2 93, heart sounds normal, jugular venous pressure (JVP) elevated. Open femur fracture		Identify the need to place the patient on cardiac and oxygen monitors and obtain IV access. Establish the clinical diagnosis of traumatic pneumothorax and identify the need for chest tube insertion. Communicate with nurse confederate to call for back up (either within the hospital or through telecommunication with sim center staff member). Learner may identify need to place addition needle thoracostomy while waiting for chest tube supplies and preparation, the nurse confederate may agree and comment that it has been placed for the purposes of this simulation.
If DONE within 2 minutes of presentation GO TO CHEST TUBE PREP 1, If NOT DONE within 3 minutes OR if learner FOCUSES ON FEMUR FRACTURE, GO TO INITIAL ASSESSMENT 2
Initial assessment 2
The learner is prompted that the patient looks worse   Prompt: Nurse comments “Looks like the needle thoracostomy isn’t enough to relieve pressure, perhaps the patient needs a chest tube”		SaO2 drops 90		Recognize worsening and/ or need to stabilize breathing before femur injury, immediately calls for backup for chest tube insertion.
GO TO CHEST TUBE PREP 1
Chest tube prep 1
Patient appears stable	Vitals stable		Communicate with the nurse and the instructor to obtain equipment and prep patient. Reposition and drape patient and deliver appropriate anesthetics.
If DONE within 5 minutes go to CHEST WALL DISSECTION 1, if NOT DONE within 5 minutes GO TO CHEST TUBE PREP 2
Chest tube prep 2
The learner is prompted that the patient looks worse		SaO2 drops 90, RR: 36		Recognize worsening and works with instructor/nurse in a more efficient manner to obtain equipment and prep patient. Learner may identify the need to place addition needle thoracostomy while waiting for chest tube supplies and preparation, the nurse confederate may agree and comment that it has been placed for the purposes of this simulation.
GO TO CHEST WALL DISSECTION 1
Chest wall dissection 1
Patient appears stable	Vitals stable		Identify anatomical landmark for chest tube placement (4th/5th intercostal space, mid-axillary line). Make cut and dissect chest wall with Kelly clamp.
If DONE within 5 minutes after the patient is prepped GO TO CHEST WALL DISSECTION 3, If NOT DONE within 5 minutes after the patient is prepped GO TO CHEST WALL DISSECTION 2
Chest wall dissection 2
Prompt - Nurse comments “The patient’s vitals are deteriorating, I think we need to speed it up”	HR rises: 130, SaO2 drops 88		Complete incision and blunt dissection with help from backup physician/instructor
GO TO CHEST WALL DISSECTION 3
Chest wall dissection 3
Patient appears stable	Vitals stable		Insert gloved finger into the cavity to ensure positioning in the pleural cavity and clear any adhesions
If DONE within 30 seconds GO TO CHEST TUBE INSERTION 1, if NOT DONE within 30 seconds GO TO CHEST WALL DISSECTION 4
Chest wall dissection 4
Prompt: Nurse comments “Is the site clear of adhesions?”	HR: 130, SaO2 drops 85		Insert gloved finger into the cavity to ensure positioning in the pleural cavity and clear any adhesions immediately. May be instructed to do so by backup physician/ instructor.
GO TO CHEST TUBE INSERTION 1
Chest tube insertion 1
Patient appears stable	Vitals stable		Advance correct end of chest tube through cavity using Kelly clamp, ensuring placement directed toward patient’s head, within pleural space and attach Pleur-Evac.
If DONE within 2 minutes GO TO CHEST TUBE CHEST TUBE PLACEMENT 1, if NOT DONE within 2 minutes OR DONE INCORRECTLY GO TO CHEST TUBE INSERTION 2
Chest tube insertion 2
Patient’s condition deteriorating	HR: 130, SaO2 drops 83		Recognize chest tube placement error and correct it. May be prompted by backup physician/ instructor on how to do so.
GO TO CHEST TUBE PLACEMENT 1
Chest tube placement 1
Patient’s condition improving		HR decreases 110, SaO2 rises 88, RR decrease 22		Secure chest tube in place using suture and dressing, attach to Pleur-Evac. Order X-ray to ensure proper placement.
GO TO END
End
Patient’s condition improving, breathing normalizes and can speak to healthcare easier.		Vitals normalize		Simulation complete