Structure: SimMan Case

Casebank Simman
1
Mind Map

Opening

  1. Candidate Identification
  2. Universal Precaution
  3. Introduction & Pt Identification
  4. PC
  5. Acknowledge & Reassure
  6. Check Monitor
  7. HPC
  8. Consent & Chaperone
  9. Position
  10. Signpost ABCDE

Airway

  1. Signpost Airway
  2. Check Airway Patency
  3. Check O2 Saturation & Any Swelling
  4. Reassess

Breathing

  1. Signpost Breathing
  2. Check RR & Trachea position
  3. Chest Examination
  4. Ix
  5. Remaining History

Circulation

  1. Signpost Circulation
  2. Check BP & Examine CRT and peripheral pulse
  3. Insert IV Cannula, Collect Blood sample and Start Fluids
  4. Examine Tummy

Disability

  1. Signpost Disability
  2. Check Temperature, Blood Sugar, GCS & Pupillary reflex

Exposure

  1. Signpost Exposure
  2. Catheterisation
  3. Leg Exposure

Final 2 minutes:

  1. To examiner- ISBAR
  2. To pt- 3P

Opening

  1. Candidate Identification:
    To examiner: I'm [First & Last Name], My GMC reference number is 7970822.

  2. Universal precaution:
    Think loud: I assume, I've taken all the universal precautions.

  3. Introduction & Pt Identification:
    To pt: Hello, I'm Dr [Last Name], one of the junior doctors here in the emergency department. Are you John Parker? Can you please confirm your age?

    • Unconscious pt (1-Hypoglycaemia): check wrist band

  4. PC:
    To pt: John, How can I help you today?

    • Unconscious pt (1-Hypoglycaemia): AVPU (Alert >Voice >Pain >Unresponsive)
      – To pt: John, Can you hear me? (Without shoulder tap >with shoulder tap >with trap pinch)

  5. Acknowledge & Reassure: If pt is conscious
    To pt: John, I see that you're in distress, but don't worry you are in safe hands now.

  6. Check Monitor: If not attached
    Think loud: I would like to attach my patient to the monitor.
    Observe vitals. Think loud: My pt O2 saturation is __.

  7. HPC:
    — Obstructed airway: Conscious who can’t speak, skip HPC (2-COPD, 3-Asthma, 4-Hematemesis, 5-Anaphylaxis, 6-Sepsis)
    — If patient is able to speak take HPC
    To pt: Signpost John, I'll be asking you few questions regarding your complaint of..
    To pt: Onset When did this start? What were you doing when it started? Also DDs
    To pt: MMA Do you have any medical condition? Are you taking any regular medication? Are you allergic to anything? Also Risk factors

    • Some 2-COPD, 3-Asthma pt can speak, so also ask
      To pt: Is any trigger that has happened?
      To pt: Have you taken any medication before coming here?

  8. Consent & Chaperone:
    To pt: John, to help you better, I'll be doing some examination, which involve exposing different parts of your body and I'll also be listening, touching, tapping and feeling them. Is that okay with you?
    To pt: We also have chaperone, for your privacy.
    Unconscious pt (1-Hypoglycaemia) say the procedure but don’t take consent.

  9. Position:

    • Semi-seating: SOB(2-COPD, 3-Asthma, 6-Sepsis)
      Think loud: Ideally I would like to place my patient on semi seating position.
    • Vomiting: (4-Hematemesis)
      Think loud: Ideally I would like to place my pt on left lateral position.

  10. Signpost ABCDE:
    Think loud: I would like to manage my patient according to ABCDE approach.

Airway

  1. Signpost Airway:
    Think Loud: Now, I'm going to start with A, which is airway.
  2. Check Airway Patency:
  • If pt can talk: Airway patent
    Think loud: As my patient is talking to me his/her airway is patent.
  • If pt can’t talk: Unconscious pt (1-Hypoglycaemia) or Obstructed airway: (2-COPD, 3-Asthma)
    Think loud: I would like to perform the Head Tilt-Chin Lift maneuver.
  1. Check O2 Saturation & Any Swelling:
  • Think loud: My pt O2 saturation is __.
    • (If O2 <94%)
      Think loud: Target O2 saturation is 94%, therefore I would like to start my patient on 100% O2 via Non-rebreathable mask (NRBM) at flow of 15L/min.
      From Trolley: Collect NRBM mask.
      To pt: John, I'm putting this mask on you, it'll help you breathe better.
    • Mask:
      – Nasal cannula: (4-Hematemesis) At 1-4L/min, 24-40% O2.
      – Venturi Mask: for COPD pt. At 24% O2
  • If lip or eye swelling: (5-Anaphylaxis)
    To pt: John, Do you feel itchy? Can you please point exactly where you feeling itchy? Pt: All over the body or area of rash.
    Think loud: As my patient is having ..(finding).. I'm thinking in terms of Anaphylaxis. I would like administer Adrenaline in 1:1000, 0.5ml, IM. (observe improvement in stridor)
    From Trolley: Collect Adrenaline.
    To pt: John, a sharp scratch is coming.
  1. Reassess:
    To pt: John, Are you feeling a little bit better now?

Breathing

  1. Signpost Breathing:
    Think loud: Now, I'm moving to B, which is breathing.
  2. Check RR & Trachea Position
    Think loud: My pt RR is __
    To pt: John, I’m going to feel you over the neck now.
    Think loud: Trachea is (centrally placed/ deviated).
  3. Chest Examination:
    From Trolley: Collect stethoscope.
    To pt: John, I'm going to uncover your chest & examine you now.
    • Inspection:
      Think loud: I'm looking for surgical scar mark, rashes or abnormal chest movement.
    • Palpation: compare temperature, B/L chest expansion
      To pt: John, Can you breathe for me?
    • Percussion: 6 sites
      To pt: I'm going to tap on your chest now.
    • Auscultation: 6 sites, also auscultate heart: 4 sites.
      To pt: I'm going to listen to your lung and heart sounds now.
      Think Loud: My pt is having added sound in ..(location).., therefore I would like to change the mask to Air-driven (2-COPD) or O2-driven (3-Asthma) Nebuliser mask ..(3-Asthma) and give medication through the mask, 5mg Salbutamol.
      From Trolley: Collect Nebuliser mask ..(3-Asthma) and 5mg Salbutamol.
      To pt: John, I'll be changing your mask now ..(3-Asthma) and giving you some medication through it, this'll help you breathe better.
      To pt: John, How are you feeling now?
  4. Ix: (ACE)
    Think loud: I would like to do few Ix for my pt ABG, CXR & 12 lead ECG.
  5. Remaining History: Obstructed airway pt: (2-COPD, 3-Asthma, 4-Hematemesis, 5-Anaphylaxis, 6-Sepsis) Pt stabilised.
    To pt: John, How are you feeling now? Do you think you can answer my few question?

Circulation

  1. Signpost Circulation:
    Think Loud: Now, I'm moving to C, which is Circulation.
  2. Check BP & Examine CRT and peripheral pulse.
    Think loud: My pt BP is __ .
    To pt: John, I’m going to press your finger nail now.
    Think loud: Ideally I would do this for 5 seconds.
    To pt: John, I’m going to feel your pulse now.
    Think loud: My pt's pulse volume is (adequate/ low) & rhythm is (regular/ irregular)
  3. Insert IV Cannula, Collect Blood sample and Start Fluids:
    From Trolley: Collect IV cannula, vacutainer and fluids.
    • Insert IV Cannula:
      – If BP normal:
      Think loud: I’m going to maintain one large bore (16G) Grey colour IV cannula in the arm.
      To pt: John, a sharp scratch is coming.
      – If BP normal: insert two in each arm.
    • Collect Blood sample:
      Think loud: I would like to collect blood sample for..
      – Common: ..FBC, RFT, LFT, U&E..
      • 2-COPD, 3-Asthma: ..ESR & CRP.
      • 4-Hematemesis, 7-PPH: .. + G&S (Group and Safe), Coagulation profile & Iron studies.
      • 5-Anaphylaxis: .. + tryptase
      • 6-Sepsis: .. + ESR, CRP, Blood culture, urine culture, lactate, G&S (Group and Safe) & Coagulation profile
    • Start Fluids:
      Think loud: I'm going to start my pt on Normal Saline 500ml in 15 min, 1L in 30 min and 2L in 1hr. Maximum 2L.
      – BP- normal: Normal Saline
      – BP- low: Hartmann Solution or Ringer Lactate (4-Hematemesis, 7-PPH, 9-Hypovolemic Shock)
  4. Examine tummy (4-Hematemesis, 7-PPH, 6-Sepsis):
    4-Hematemesis, 7-PPH:
    Think loud: I would like to activate massive hemorrhagic protocol & arrange 6 units of pre-warmed O negative blood. If my pt's BP doesn't improve on fluids then I'll transfuse 2 units of blood at 2 ml/min.

Disability

  1. Signpost Disability
    Think Loud: Now, I'm moving to D, which is Disability.
  2. Check Temperature:
    Think loud: My pt temperature is __
  3. Check Blood Sugar:
    Think loud: I would like to collect blood sugar now.
    From Trolley: Collect glucometer and strips.
    To pt: John, a sharp scratch is coming. Normal: 4 to 5.9 mol/L
    (1-Hypoglycaemia)
    Think loud: I would like to administer 10% Glucose 50ml every min for 5 minutes.
    From Trolley: Collect 10% Glucose 50ml.
  4. Check GCS-
    To pt: John, can you please move your leg?
    Think loud: My pt is opening his eyes spontaneously, he is speaking and following verbal commands, hence his GCS is normal.
  5. Check Pupillary Reflex: (10-Opioid overdose)
    From Trolley: Collect torch.
    To pt: John, I'm going to shin light in your both eyes now.

Exposure

  1. Signpost Exposure
    Think Loud: Now, I'm moving to E, which is Exposure.
  2. Catheterisation: (Except- 2-COPD, 3-Asthma)
    Think loud: I'm going to catheterise my pt.
    From Trolley: Collect Catheter.
    To pt: John, we'll be putting a flexible tube from your front passage.
  3. Full exposure:
    To pt: John, I'm going to expose your leg now.
    8-ALI: Quick ABCD, in E: 6P
    Pain, Pallor, Poikilothermia, Pulselessness, Paresthesia, Paralysis.

Final 2 minutes

  1. To examiner: ISBAR
    – Introduction: (Your Name, Position & Department) (Pt name & age)
    – Situation: PC
    – Background: PMH
    – Assessment: Positive findings
    – Recommendation: Admit, Rx, Senior
  2. To pt: 3P
    – Past: How are you feeling? Narrate story & Explain condition
    – Present: Explain Management
    – Future: Explain Recommendation
Note

Think loud: Thinking loud is indirectly talking to the examiner, as you can’t directly talk or even make eye contact. While thinking loud you can look at the monitor.

From Trolley: You collect instruments from the resuscitation trolley before conducting and informing it to the patient.

To pt: You inform everything to the patient before conducting any procedure.

Scenario number

1-Hypoglycaemia
2-COPD
3-Asthma
4-Hematemesis (Post Endoscopy & Peptic Ulcer)
5-Anaphylaxis
6-Sepsis (Post UTI & Urosepsis - Post TURP)
7-PPH
8-ALI
9-Hypovolemic Shock
10-Opioid overdose
11-RHD
12-PCPM
13-Postural hypotension
14-Hyponatremia
15-Hypokalaemia
16-AF
17-HF-AF-PE
18-Arrhythmia
19-SVT

PCPM - Post Caesarian Pain Management

9 Likes
2

Suggestion, It isn’t appropriate say to the patient how can I help. As it would be a medical emergency, rather saying “can you tell me what happened?” would be more appropriate.

4 Likes
3

I agree with your logic. When this was written, the thought process went into this was to ask a open ended question.

4 Likes
4

All the Venturi masks have the % and litres written on them in case you forget it just look at it on the body

“be wise or you ruin greatly”

Be - Blue - 24% - 4L/m

Wise - White - 28% - 4L/m

Or - Orange - 31% - 6L/m

You - Yellow - 35% - 8L/m

Ruin - Red - 40% - 8L/m

Greatly - Green - 60% - 12L/m