Failure: I thought I knew how to make this patient better but I am making them worse. What is different about this patient in this environment?

• Mannequin

• IV equipment

• IV fluids

• BP cuff, thermometer

• Nurse

• Ultrasound machine

• Antibiotics

• Glucose monitor

Adjustment/humility: I learned that having false assumptions that patients will always be physiologically the same as those I am used to, can at times be harmful.

Ideal Emotional Response DURING Case Ideal Emotional Response AFTER Debriefing

Developed by Laurel Guthrie, MD and Jukes P. Namm, MD

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

KEY MEDICAL MANAGEMENT REMINDERS

Differential forRLQ pain

Management ofacute appendicitis

Supplies• Recognize and clinically diagnose acute appendicitis• Appropriately manage acute appendicitis• Identify postoperative nausea and vomiting• Develop differential for patient’s symptoms• Appropriately manage malaria

Ideal Medical Objectives

Presentation with acute appendicitis

FIRST STATEImprove

SECOND STATE

Give fluids, abx,take to OR

Fevers, nausea, vomiting, headache

THIRD STATEImprovement with administration of quinine or other antimalarials

FOURTH STATE

Think ofdifferential

Monitor for standardpostop recovery

• Clinical exam• Ultrasound• Open appendectomy• Abx: broad spectrum• Remember parasites can cause appendicitis

Clinical signs/symptomsof malaria

• Rigors• Recurrent cyclic fevers• Headache• Myalgias, diarrhea, mild jaundice, cough, vomiting• Hypoglycemia

Management of malaria

• Consult national guidelines• Treat hypoglycemia• Hydrate patient• Transfuse to keep Hgb >5• Consider abx• Give oral meds if tolerated: - Chlorquine +/- primaquine - Artimesinin-based combination therapy (artesunate) - Quinine• Give IV medications if PO not tolerated• Monitor for severe malaria, signs of end organ dysfunction

PROCEED TO CASE PRESENTATION, EXPECTED INTERVENTIONS, AND OBSTACLES

SURGERY CASE 5: ACUTE APPENDICITIS

• 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

SURGERY CASE 5: Provide information only as it is requested

PROCEED TO SURGERY CASE 5 DEBRIEFING SCRIPT

POTENTIAL INTERVENTIONS AND OBSTACLES

STOP CASE WHEN THE FOLLOWING ARE TRUE

Presentation: You are called to the casualty ward to see a 15 year old male with abdominal pain and nausea.

CC: Abdominal pain and nausea

HPI: This is a 15 year old male with worsening abdominal pain and nausea for the past 24 hours.

PMH: unknown

FH: none

Social: In school, lives in a village compound with 12 other family members

Meds: none

All: none

Vitals: T 38.3 C HR 102 R 21 BP 108/84 O2 98%GEN: Awake and alert, in mild distress

HEENT: Spontaneous eye opening, dry mouth

Resp: Mild tachypnea, breath sounds presentbilaterally

CV: Mild tachycardia, no murmurs or arrhythmias

Abd: Tender to palpation of right lower quadrantwith rebound and focal guarding.

Neuro: Oriented x3, follows commands

Ext: Thin, warm, well-perfused

Residents have encountered obstacles and found ways to work around them

Patient has undergone appendectomy and malaria has been appropriately diagnosed and treated

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

ExpectedIntervention Obstacle Possible

Solution(s) Outcome(s)

KUB shows no free air,no dilated bowel loops

Get KUB –will take timeGo directly to OR

No CT, ultrasound is brokenUltrasound or CT

Improved mentation after fluids, improved blood pressure

Intermittent bolusesNo pump to run fluidsFluid resuscitation

Delay (?POCT machine broken), Hgb low normal, WBC 20

Call tech from homeOnly POCT hgb available; have to call lab technician at home 15 min walk away in order to obtain CBC

Check labs

CBC shows anemiaGet CXR, KUBNo CT, only dipstick for UA, CBCIdentify postoperative fever,get labs, KUB, ?CT scan, UA

Positive for P. falciparum, improves after tx with quinine or other antimalarial

Look at peripheral smear under microscope, treat empirically

No malaria quick test availableTest for malaria

References:

Oxford Handbook of Tropical Medicine, Fourth Edition (2014). pp. 34-67, 308-309. Sabiston Textbook of Surgery, Twentieth Edition (2017). “The Appendix”, pp. 1296-1311.

SURGERY CASE 5 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: “What aspects of the case do you think you managed well?” “Were there aspects you’d wish to manage differently the next time?” “What was different about this case management or flow than what you are used to?” “How might you see yourself reacting to those changes abroad? How might your reactions be perceived by the local medical providers?” “What obstacles did you encounter to providing the care that you felt the child needed?” “How did you overcome those obstacles?”

Review the individual obstacles on Page 2 of the case and the possible solutions. Address WHO recommendations for diagnosis and management of malaria.

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...