Failure – “I thought I knew how to manage this patient, but I am making them worse. What is different about this patient?”

• Adult mannequin• IV/IO• Central line• IV fluids• Oxygen nasal

cannula/NRB

• Blood • CBC w or wo

diff, blood smear• Rapid HIV• CXR

Adjustment/Humility – I have learned that patients may have different physiology and disease burden and treating them the same as patients I’m used to can be harmful.

Ideal Emotional Response DURING Case Ideal Emotional Response AFTER Debriefing

EMERGENCY MEDICINE CASE 4: SEPSIS Developed by Jessica Schmidt, MD

IDEAL CASE FLOW: Specifics less important than flow – Remember goal is to allow frustration

KEY MEDICAL MANAGEMENT REMINDERS

Identification of malnutrition in Adult

Supplies

• Recognize the presentation of acute sepsis in a patient with immunocompromise and malnutrition

• Recognize that the management of shock may be different in immunocompromised and malnourished patients and that aggressive fluid resuscitation or vasopressors may be fatal

• Consult the literature for management of sepsis in low-resource settings

Ideal Medical Objectives

• Allow case to mimic slow pace often found in resource-limited medical environments. Case may take over 30 minutes to complete.

• Allow ample time for participants to overcome obstacles from difficulty in communication, slow sharing of information, resisting prompting in problem solvingas much as possible.

Keys to Reaching Desired Emotional Response

Not necessarily based on BMI, malnutrition occurs when energy intake is less than energy needsPhysical exam findings in malnutrition: cachexia, temporal wasting, loss of periorbital fat pad, cheilosis, brittle hair or hair loss, fissured nails, loss of subcutaneous fat to upper arms/legs/buttock, poor hand grip, muscle wasting, fluid retention (ascites, pedal or scrotal edema)

WHO HIV/AIDS: A Guide For Nutrition, Care and Support http://www.who.int/hac/techguidance/pht/8518.pdf

Food and Nutrition Technical Assistance: https://www.fantaproject.org/sites/default/files/resources/Namibia%20flipchart%20algorithm%20adults_Sept2010.pdf

Treatment of Sepsis in Malnourished AdultRecognizing sepsis: SIRS criteria (T >38 or < 36, HR > 90, RR >20, wbc >12 or <4) or qSOFA (GCS <15, RR >22, SBP <100)In suspected sepsis, initiate antibiotics/antimalarials (in endemic areas) early- even be before source identified In malnourished patients, aggressive volume expansionwith IVF or blood transfusion may lead to worsening clinical outcomes due to respiratory failure likely from third spacing and pulmonary edemaStart with IL IVF and then MIVF, can give additional bolusas needed, lower MAP goal ≥ 60Monitor for signs of respiratory distress/fluid overload with pulse ox, RR, and lung auscultationStop IVF if respiratory status appears compromisedConsider transfusion if Hb <7ART should NOT be initiated in the setting of acute illnessif new diagnosis due to concern for IRIS

Effect of an Early Resuscitation Protocol on In-hospital Mortality Among Adults With Sepsisand Hypotension: A Randomized Clinical Trial.Andrews B, Semler MW, Muchemwa L, Kelly P, Lakhi S, Heimburger DC, Mabula C, Bwalya M, Bernard GR.JAMA. 2017 Oct 3;318(13):1233-1240. doi: 10.1001/jama.2017.10913.N Engl J Med. 2017 Jun 8;376(23):2223-2234. doi: 10.1056/NEJMoa1701380. Epub 2017 Mar 21.Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis.PRISM Investigators, Rowan KM1, Angus DC2, Bailey M3, Barnato AE2, Bellomo R3, Canter RR1, Coats TJ4, Delaney A5, Gimbel E2, Grieve RD6, Harrison DA1, Higgins AM3, Howe B3, Huang DT2, Kellum JA2, Mouncey PR1, Music E2, Peake SL3,7,8, Pike F9, Reade MC10, Sadique MZ6, Singer M11, Yealy DM2.

PROCEED TO CASE PRESENTATION, EXPECTED INTERVENTIONS, AND OBSTACLES

• Medications: morphine, paracetamol, ceftriaxone, dopamine, ART,artesunate

Patient brought into ER with lethargy and fever

FIRST STATE

Patient brought into ER with lethargy and fever

FIRST STATESome improvement in blood pressure, MAPstill less than 60

SECOND STATEPatient slowly improves over days

THIRD STATE

Blood pressure improves but develops tachypnea, low O2 sat

SECOND STATEPatient continues to worsen and codes

THIRD STATE

Early aggressive IVF Resp distressNOT recognized

Given gentle IVF No clinicalchange in status

EMERGENCY MEDICINE CASE 4: SEPSIS. Provide information only as it is requested

PROCEED TO EMERGENCY MEDICINE CASE 4 DEBRIEFING SCRIPT

POTENTIAL INTERVENTIONS AND OBSTACLES

STOP CASE WHEN THE FOLLOWING ARE TRUE

Introduction:

CC: weakness and fever

HPI: A 34 year old male patient in Uganda (tertiary referral center) presents with fever for two days and inability to get out of bed due to fatigue. He is carried in by family members. No headache or neck stiffness. No rashes. He appears confused and is not able to answer questions.

PMH: unknown

FH: mother with type II DM, poorly controlled

SH: Lives in city with uncle and two cousins, works day labor

Medications: none Allergies: None

Pertinent Positives on Exam (assume normal if not noted)

GEN: cachectic, lying still on stretcher, eyes closed HEENT: normal conjunctiva, PERRL, orbits sunken, neck supple, no LAD RESP: mild tachypnea, crackles in RLL, no retractions, no wheeze CV: tachycardia, no murmur, warm extremities ABD: mild distension, no TTP, +fluid shift NEURO: awake and alert but somewhat slow to answer EXT: Muscle wasting in upper arms and thighs SKIN: no rash

Initial Vitals: (ONLY GIVE WHAT IS ASKED FOR): Wt – 48 kg Height 1.64 m T 39.0 HR 144 RR 22 BP 76/40 O2 98% on RA, blood sugar 86

ExpectedIntervention Obstacle Possible

Solution(s) Outcome(s)

PNA seen onCXR if obtained, elevated wbc, normal urine

Temporary improvement in BP (see algorithm above)

If no antibiotics, worsening clinical status

If started, vomiting and worsening clinical condition over days due to IRIS

Start empiric treatment based on exam findings

Possible solutions: IO or central line, or ultrasound-guided line if available

Initiate empiric antibiotics

Initiate ART or defer until patient improved

No blood cultures, patient not making urine, CXR not available until tomorrow

Nurse unable to place line

Labs/CXR not yet obtained

No CD4

Sepsis workup withcbc, blood smear, CXR, urine, blood cultures, rapid HIV

Initiate IVF

Initiateantibiotics/antimalarials

Start ART if HIVidentified

Participants have encountered obstacles andfound ways towork aroundlimited resources

Participants have identified sepsis and initiated antibiotics

Participants have identified that IVF/vasopressors eventually made patient worse

Enough time has passed to allow for sense that case takes longer to manage than at home

EMERGENCY MEDICINE 4 DEBRIEFING SCRIPT1

Remember: Goal of debriefing is not to lecture, but to facilitate discussion

1Adapted with permission from Eppich, W., & Cheng, A. (in press). Promoting Excellence And Reflective Learning in Simulation (PEARLS):Development and Rationale for a Blended Approach to Healthcare Simulation Debriefing. Simul Healthc.

Setting the Scene: “We are going to spend the next 20-30 minutes debriefing the case. We are going to focus our attention on the emotions encountered but will also address the management of the case. We also want to focus on how you overcame obstacles often encountered when managing a case like this in a resource-limited environment.”

Reaction: “How did that feel?” Pay attention to cues pointing to overcoming lack of knowledge with ability to use available resources.

Description/Clarification: “Can someone summarize what the case was about from a medical standpoint by taking us through what just happened? I want to make sure we are all on the same page.”

You may need to clarify and keep this moving by asking follow up questions. “What happened next?”

Application/Summary: “Is there anything you learned during the course of this case, that has changed your perspective about your experience abroad?”

End with each learner providing a take-home point from the case

Analysis:“Remember, the goal is to get the participants to discuss how they dealt with their perceptions of different views of death and futility. Be sure to explore these themes.

• “What obstacles did you encounter to providing the care you felt this patient needed?” • “How did this case differ than care the patient would likely receive at your home institution?” • “How might your reaction to the lack of resources or lack of treatment differ from that of the local providers?

How might they view your reactions?” • “Were there parts of the case you wished you would have changed or done differently” • “How did you feel about the final outcome of the case; how do you think the family felt?”

Framework for Formulating Effective Debriefing Questions – Choose one prompt from each column

Observation Point of View Question

I noticed that... I liked that... How do you all see it?

I saw that... I was thinking... What were the team’s priorities at the time?

I heard you say... It seemed to me... How did the team decide that...

RESULTS

CBC: 14 wbc, 88% neutrophils, Hb 7.2, Hct 28, plts 254Blood smear: no parasitesUrine: normalHIV positive

CXR