| Pre-Scenario |
| You are a third-year medical clerk. A 56-year-old accountant presents with shortness of breath while recovering in the orthopaedic ward 12-hours following a total knee replacement (TKR). The patient received a spinal anesthetic with an adductor canal nerve block prior to the surgery. The patient is currently on a Patient Controlled Analgesia (PCA) pump which releases 2 mg of morphine on patient demand with a 5-10 minute lockout period with a maximum dosage is 10 mg of morphine per hour. The medical chart is available for your review and there is a single nurse confederate in the room. |
| History |
| Allergies |
Penicillin, peanuts |
| Medications |
Simvastatin 40 mg PO once daily, quinapril 20 mg PO once daily, morphine 10mg/hour |
| Past Medical History |
Hypertension, hypercholesteremia |
| Social History |
Accountant, married with 3 grown children, smoker, occasional cocaine use |
| Family History |
Mother died from bowel cancer at age 76, father and two brothers are alive with controlled hypertension, one sister with type 2 diabetes |
| Initial Vitals |
Heart rate (HR) 84, blood pressure (BP) 110/76, SaO2 92% |
| Physical Exam |
Appears pale and diaphoretic. Alert and oriented to person, time and place but moderately distressed. Good air entry bilaterally, no adventitia, showing increased WOB. Irregular heart sounds: S1, S2 and S3, JVP 6cm, no murmur or precordial rub. No unilateral leg swelling or calf tenderness. |
| Initial Expected Actions |
| 1. Focused History and Physical Exam |
| 2. Order ECG |
| 3. Recognize Anterior ST Segment Elevation |
| 4. Order Crash Cart |
| 5. Call for Help and Provide Handover to Attending Physician |
| Begin Scenario |
| Objective 1: Recognize when an ECG is required in the perioperative period |
| Stage |
Vitals |
Expected Actions |
No Action by Learner |
| Patient complains of shortness of breath and appears diaphoretic |
HR 84, BP 110/76, SaO2 92% |
Focused cardiac history and physical exam, order ECG |
Prompt by confederate nurse: “I used to work in the cardiac care unit and it looks like he is having an infarct” |
| Objective 2: Recognize a perioperative MI following a non-cardiac surgery |
| Stage |
Vitals |
Expected Actions |
No Action by Learner |
| ECG Analysis |
HR 100, BP 90/60, SaO2 92% |
Recognize anterior ST-segment elevation |
Prompt by confederate nurse: “He doesn’t look very good. I am going to get the crash cart” |
| Objective 3: Activate an appropriate medical response including ordering a crash cart and calling for help from an attending physician |
| Stage |
Vitals |
Expected Actions |
No Action by Learner |
| Initiate medical response |
HR 100, BP 80/50, SaO2 88%, ECG shows Sinus tachycardia and premature ventricular contractions (PVCs) and anterior STEMI |
Order crash cart, call for help from senior physician |
|
| Patient handover |
HR 100, BP 80/50, SaO2 88% |
Provide patient details to senior physician |
