Analgesia.
Specialist consultation (general surgery and/or gastroenterology) for intervention:The type of intervention will depend on etiology:Endoscopic retrograde cholangiopancreatography for biliary drainage, sphincterotomy, stone extraction, biliary stent placement.Open surgical drainage.If a patient is initially seen at a facility without these consult services, transfer to the nearest facility that has these resources should be undertaken [2, 3].
Debriefing Plan
Allow approximately 20–30 minutes for debriefing after this scenario.
Potential Questions for Discussion
What are signs that a patient may have sepsis?
What is the appropriate management of a patient with sepsis?
How can you assess for end‐organ dysfunction in a patient with sepsis?
What are the indications for vasopressor initiation in sepsis?
What is Charcot's triad?
What is Reynold's pentad?
REFERENCES FOR SEPSIS
1 1. Ahmed, M. (2018). Acute cholangitis – an update. World J. Gastrointest. Pathophysiol. 9 (1): 1–7.
2 2. Ely, R., Long, B., and Koyfman, A. (2018). The emergency medicine−focused review of cholangitis. J. Emerg. Med. 54 (1): 64–72.
3 3. Mayumi, T., Okamoto, K., Takada, T. et al. (2018). Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis. J. Hepatobiliary Pancreat. Sci. 25 (1): 96–100.
SIGMOID VOLVULUS
Educational Goals
Learning Objectives
1 Assess a patient presenting with acute abdominal pain, utilizing a focused history and physical exam (MK, PC).
2 Formulate a differential diagnosis for acute abdominal pain (MK).
3 Recognize the signs and symptoms of a possible intestinal obstruction (MK).
4 Demonstrate appropriate utilization of lab tests and imaging studies to evaluate abdominal pain (MK, PC).
5 Recognize an agitated patient and use verbal de‐escalation and negotiation skills (ICS, P).
6 Demonstrate professionalism while treating a patient with behavioral issues (P, ICS).
7 Demonstrate appropriate surgical consultation (P, ICS, SBP).
Critical Actions Checklist
Recognize clinical signs of obstruction (MK).
Obtain appropriate IV access (PC).
Obtain imaging (MK).
Administer analgesic medication and antiemetics for patient's symptoms (PC).
Recognize an abnormal bowel gas pattern (concerning for obstruction) on x‐ray and/or CT (MK).
Maintain a calm and professional composure while communicating with a difficult, disruptive patient (PC, ICS, P).
Consult general surgery for emergent management of volvulus (P, ICS, SBP).
Simulation Set‐Up
| Environment: | ED treatment room. |
| Mannequin: | Adult, male, simulator mannequin moulaged to appear disheveled (e.g. clothes may be slightly dirty and/or torn or used in appearance). |
Props:
Images (see online component for sigmoid volvulus, Scenario 1.3 at https://www.wiley.com/go/thoureen/simulation/workbook2e):Abdominal x‐ray showing evidence of distended sigmoid colon (Figure 1.16).Radiology report of abdominal x‐ray (Figure 1.17).CT abdomen/pelvis with IV contrast (static image 1‐cut) (Figure 1.18).Radiology report of sigmoid volvulus (Figure 1.19).ECG showing sinus tachycardia (Figure 1.20).
Laboratory tests (see online component as above):Complete blood count (Table 1.22).Basic metabolic panel (Table 1.23).Liver function panel (Table 1.24).Lipase (Table 1.25).Lactic acid (Table 1.26).Troponin (Table 1.27).Coagulation panel (Table 1.28).Urinalysis (Table 1.29).Urine microscopy (Table 1.30).
Available supplies:
Adult code cart with basic airway supplies.
Medications:0.9% saline/LR IV bags.Pre‐labeled IV bags:Broad‐spectrum antibiotics.Pre‐labeled syringes:Analgesic medications (e.g. morphine, fentanyl, hydromorphone)Antiemetics (e.g. metoclopramide, ondansetron)Antipsychotics (typical of your institution examples include haloperidol, risperidone, etc.)Benzodiazepines (lorazepam, diazepam, midazolam).Optional: emesis basin.
Distractor:The patient's behavior is a distractor and the learner must demonstrate de‐escalation and redirection techniques to obtain history and physical exam.
Actors
Patient has chronic, poorly controlled schizophrenia. He is uncooperative and agitated with all the questioning and will require redirection and verbal de‐escalation throughout the scenario. He is difficult to obtain history from, stating: “I am sick of answering all these questions.” Eventually he will comply with the team's treatment plan (i.e., IV access, imaging, etc.).
ED nurse is experienced and can cue the learners as needed.
EMS may be an actor or may provide report via the phone (as a radio call from the field).
General surgery consultant available via phone consultation.
Case Narrative
Scenario Background
A 50 year‐old‐man presents with worsening abdominal pain for the past two days. It is associated with intractable nausea and vomiting. He has not had a bowel movement for the past three days, which is unusual for him. His group home called because he has been vomiting and his pain is getting worse. He has no reported fever, chest