Emergency Medicine Simulation Workbook

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.

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.

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 discomfort, shortness of breath, or urinary difficulties.

A 50 year‐old man lying on a hospital stretcher is moaning in pain. Patient is occasionally retching into a basin.

See flow diagram ( Figure 1.21) for scenario changes based on learner actions.

For all learners, the case should begin with obtaining a complete history, and performing a thorough physical exam. The nurse can help the learners to set the patient up on the monitor.

The learners should order laboratories, imaging studies, and appropriate medications (such as IV fluids, antiemetics, and pain control).

Throughout the scenario, the patient will be very disagreeable to the plan of care. He will be difficult to obtain history from and will be angry during the examination, “because that hurts me!” He will also initially refuse IV access and will require discussion about why this is necessary. He will then become hostile about the possibility of needing a CT scan because, “Aren't you a doctor? Can't you just figure it out based on what I've told you?” Ultimately he will require multiple efforts at verbal de‐escalation before agreeing.

After the learner discusses the diagnosis of volvulus and the need for surgical evaluation with the patient, he will become upset and frustrated. He will calm down if the learner takes the time to listen to him and acknowledge his frustrations.

The trigger for the end of the case will be consultation with surgery for intervention and admission.

Epidemiology

Third leading cause of large bowel obstruction worldwide, following cancer and complications of diverticulitis [1].

Risk factors:Elderly.Individuals with chronic constipation and/or a high fiber diet.Nursing home or long‐term care facility patients [2], including patients with chronic psychiatric disorders and dementia.

Sigmoid colon becomes stretched, attachments to the abdominal wall loosen, allowing colon to twist.

Ischemia occurs, which can progress to gangrene and perforation.

Common symptoms:Abdominal pain.Bloating.Constipation/obstipation.Nausea/vomiting (may be feculent).

Exam findings:Pain on palpation.Abdominal distension.High‐pitched bowel sounds.

Lab tests not diagnostic.

Imaging:Abdominal radiographs:Distended loops of colon with or without air‐fluid levels“Bent inner tube sign” of distended colon in a U‐shaped pattern and extending from the pelvis toward the right upper quadrant.Paucity of gas in the rectum.Free air under the diaphragm, if perforation has occurred.Abdominal CT:Dilated loops of bowel with evidence of obstruction.“Whirl sign” or twisting of the mesentery.“Bird's beak” sign if rectal contrast has been given.Absence of gas in the rectum.Transition point within the bowel.Late findings that may indicate bowel necrosis or perforation: pneumatosis intestinalis, portal venous gas, loss of bowel wall enhancement.

Analgesia.

Antiemetics.

IV fluid resuscitation.

IV antibiotics:Recommended for signs of peritonitis, perforation or sepsis.

Emergent surgical consultation:Flexible sigmoidoscopy.Recommended initial treatment strategy.Can be both diagnostic and therapeutic unless patients have perforation or significant ischemia.Laparotomy:If detorsion with endoscopy is not able to be performed, may be required.

Provide approximately 20–30 minutes for debriefing after this scenario.

What are some helpful strategies for dealing with difficult patients or patients with behavioral issues?

What are risk factors for sigmoid volvulus?

What abnormalities can be seen on abdominal x‐ray in a patient with sigmoid volvulus?

What is the management for a patient diagnosed with sigmoid volvulus? Is surgery always required?

1 1. Bauman, Z.M. and Evans, C.H. (2018). Volvulus. Surg. Clin. North Am. 98 (5): 973–993.

2 2. Gingold, D. and Murrell, Z. (2012). Management of colonic volvulus. Clin. Colon Rectal Surg. 25 (4): 236–244.