EM Oral Board Case G. Hutchinson © 1989-2020 D Collman MD/Collman Institute Inc. All rights reserved. No duplication in any form is permitted without the written consent of the Collman Institute and/or Dr Collman.

Emergency Medicine Interactive Case Management

(C) 19 89–2020, Dwight Collman, MD., DABEM, DABFM

CASE: GARY HUTCHINSON

DIAGNOSES:

1.  HYPOVOLEMIC SHOCK

2.  LEFT-SIDED MASSIVE HEMOTHORAX

3.  SPLENIC INJURY

SUMMARY OF THE CASE- An EXR [Examiner] will introduce themself, ask you if you understand how the examination works [You respond, “Yes” and this begins the timing of the case. Each EM Board has different time limits for single and multiple patient encounters. Most are 15-20 min interactions with up to 5-10 min of pathophysiology questions. Often you are not asked a question [one of the 8 performance ratings. This is because you demonstrated you understood this portion of the case and are given the fulll credit in that circumstance: think of the total as 8 points per PR [performance rating]; with 8 PRs there are a total of 64 maximum points. This is modified by 4-5 CAs [Critical Actions] and others DAs [Dangerous Actions]. ABEM has now, for years, scored the oral exam on a curve with your testing group for your particular test date. This has raised the minimum required passing score. I discuss this in some detail on the Home Page and I will discuss it further on a separate page devoted to each: the PFs, the CAs, and the DAs. OK…here is your first sample case! It has a lot of extra details to explain the workings of the oral examination. EXRs have all the theoretical potential pathways and have planned responses and alternate algorithms…ABEM published this set of facts years ago. Each year they provide the Board Certified EPs [emrgency physicians] with an annual report that details some of these facts. I was board certified as soon as I was eligible in the 1980s and I created the 52 cases before I took my oral examination because I was already helping other physicians and needed materials to do that]. I also supplied ABEM with all of my cases which they reviewed and accepted as my own works. OK lets begin this sample case…enjoy!

Gary Hutchison is a 36-year-old male who was involved in a motorcycle accident just prior to admission to the ED. He was transported by the paramedics on a backboard and has a complaint of neck pain and left chest pain. He also complains of abdominal pain.

VITAL SIGNS: The EXR hands this data to you…do not read it aloud…often in clinical practice you do not look at this data as much as the patient and just manage them. It is like auscultation of the heart…it is not part of the primary survey…ever! You just assess perfusion in those first few seconds to make your decisions such as placement of intravenous lines and or a need for blood. The EXR always starts their 15 minute clock when you pick up your pencil..so sit relaxed with your arms at your sides…that shows you are comfortable at work…they want that quality! I will show you later how to use the CAN sheet they provide…that is another whole discussion and is also covered in my 330 pg syllabus you should read for the year prior to your oral examination. You may order that from this website just by sending me a msg or text me at 51-305-8163. I will be happy to discuss your needs when you call…its best to call when you are not at work so you are not rushed. I will usually respond in under 24 h.

BP:  87/50 mmHg P:  123 R:  24 [and shallow if requested by the CAN

T:  98.2 F

PROGRESSION OF THE CASE (PRIMARY SURVEY)

  1. After a primary survey this patient is a clear case of multiple trauma involving a high-speed motorcycle collision.  [Single driver; No other vehicle involved.].
  2. If a general impression as requested, the examiner made state, “This is a well-developed white male lying on a long board on the stretcher.”  NONE OF THIS INFORMATION IS PROVIDE IF NOT SPECIFICALLY REQUESTED BY THE CAN [The CAN must request a general impression].
  3. The CAN Should indicate that the patient should be carefully remove from the spine board and if the patient clothing be cut way during the primary survey.  [some CANs may opt to examine the entire bony spine during removal of the long board.  They should indicate there are multiple helpers involved to control the head torso body and extremities and out the entire cervical thoracic lumbar and sacral spine be palpated as well as a quick visual inspection of the posterior body.
  4. Since the patient complains of neck pain his cervical spine should be immobilized and evaluated both clinically and radiographically.   The airway is patent w/o sonorous nor gurgling breath sounds.  If requested a gag reflex is present.  The CAN should request a tight-fitting high flow oxygen mask after describing the correct technique for helmet removal [2-person technique As described by the American College of surgeons in ATLS]

5.  The patient is hypotensive and should receive two, 14–16 G intravenous lines with an appropriate fluid resuscitation using LR, application of a high concentration of oxygen, cardiac and pulse oximetry monitoring and evaluation of an EKG strip:  [sinus tachycardia @ 120 bpm].  Note:   typically the EXR Will provide clinical data such as a rhythm strip for the CAN To interpret.  [In each team manual there will be inserts such as a rhythm strip for the EXR to hand to the CAN to vocalize their interpretation 

G Hutchison: case study copyright 19 89–20 20 the Collman MD and the Collman Institute. All rights reserved. These materials are the property of the Collman Institute Inc., and must be returned at the end of each conference day.  Photocopying or any other means of reproduction by any pbarticipant is strictly forbidden without the expressed written permission of the author and the Collman Institute Inc.

Even the latter is not always necessary if your actions prove you understood the finding.  Check the inserts prior to the case study as you are find often there will be several such inserts that should only be provided when they are requested; note that if a CAT scan is requested before completing both the primary and secondary survey such a study should not be revealed yet to the CAN and this should be marked as a DA [dangerous action]:  this is inappropriate data acquisition one of the eight performance ratings and in a hypotensive patient could reveal a flat IVC sign which proves that a patient was not resuscitated prior to having an abdominal CT.

(In this particular patient a CAN may opt to perform a bedside FAST or EFAST study;  EXRs May have the results of the findings or may actually show such a study and ask the CAN to interpret it.  In this patient it would show a splenic injury consistent with a large splenic laceration and intrabdominal bleeding.  Circumstances in hospital policies very as well as time of day so either of these methods could be appropriate as long as the patient is properly resuscitated and demonstrates resolution of hypotension prior to a CT scan.  Please note that a blood pressure of 90/60 mmHg would still be considered hypotension this is the life blood pressure must be greater than 110 mmHg with a pause less than 90-100 bpm and not revert to Hypertension/tachycardia if a CT scan is ever ordered.  

6.  2 L of LR should be rapidly infused. Level one infuser may be requested that is available.

7.  By percussion the patient has a large [massive] left hemothorax [perceived as dullness to percussion compared to the right side; the latter would be reported as tympanitic to percussion [only if requested].  Other signs or signs of left chest injury could include palpation of subcutaneous emphysema as well as rib crepitation in the left anterior axillary line with rib tenderness. There’s no obvious flower segment by breath sounds are decreased on the left [Only if requested].  This patient would obviously complain of chest wall pain with palpation or percussion of the left chest. The patient might also display bruising over the left chest.

8.  The CAN should recognize that the physical findings indicate blunt trauma with an air leak and placed a chest tube on the left side describing the technique and anatomical landmarks such as the triangle of safety in the anterior axillary line. The chest tube should be tunneled over the superior rib After aseptic technique for cleansing and draping and local anesthesia. They see AN should ask any awake patient if they have any medication allergies.  [This patient will indicate no no medication allergies].  There is an initial output of 350 ML of blood in addition to some air from the left chest tube which should be a 36 to 40 French tube. Big CAN should connect the chest tube to underwater seal apparatus and order a portable CXR.  Later, ongoing blood loss from the chest tube indicates a massive hemothorax which would be an indication to take the patient to the operating room for thoracotomy. This should not be revealed until a full primary/secondary survey as well as any other necessary interventions are performed.

9.  Despite the interventions, the patient continues to be hypotension and requires further treatment with 2-4 u TS pRBCS…Another indication that the patient needs to go to the operating room immediately.  [Remember that in each simulation injuries will vary and other procedures such as traction or application of a splint, pelvic cravat or binder [for pelvic Fx] or reestablishing a pulse may be indicated for a long bone fracture as common examples.  Also, bilateral femur Fxs can cause enough blood loss to causevsudden death.  [Remember that any long bone fracture should be studied says that do use one joint above and one joint below the injury are obtained].  Also recall, that in multiple trauma simulation, as in real life, transfer to a  

trauma facility should not be delayed for a CT scan or a radiograph; one never wants a well-documented arrest due to hypovolemic shock.  Likewise, Failure to recognize the need for transfusion would also be marked as a dangerous action or critical omission.  

Some candidates who are highly skilled at bedside ultrasound may do a more thorough evaluation which can be done in a matter of seconds including looking for a pneumothorax, hemothorax, a single view of the heart timer the IVC, the bladder and retrovesical space as well as Morrison‘s pouch and the splenorenal spaces.  Sometimes repeat study is indicated at the bedside.  This also includes repeating a secondary survey and even a primary survey when vital signs suddenly deteriorate in any simulation.

The CAN Should continue to evaluate for other injuries because of the persistent hypotension and or new onset hypotension.  They should also check and make certain that all tubes are functioning properly and ultimately this patient would be rapidly incubated anticipating the need for the OR.  RSI intubation is common place and well accepted.  If a patient is comatose with a GCS less than 8, all of these patients require intubation [and the lower the GCS score the less of the need for medications and the greater the need for early intubation.  AC AN should be able to recite do use of mild hyper ventilation to keep a PCO to between 30 and 35 for a patient with a closed head injury.  A volume cycle ventilator is indicated If the patient is not going to receive BVM/ETT ventilation. [EX ours may ask for the size of the ETT/the type of blade used, [Miller or Macintosh, But typically these questions are not asked in multiple trauma patients due to time constraints but they could be asked as pathophysiology questions.  Most EXRs respond, “Done, what would you do next?”After any procedure especially with a confident candidate who they will assume understand the procedure-confidence in tone and brevity of language matters!…This gives the EXR is a feeling of confidence to give the CAN credit for displaying confidence.  If he can is too detailed the examiner will simply say, “done…next!”  To conserve CAN Management time. EXR’s are always attempting to maximize a CAN’s score; so they always avoid time delays unless they have been specifically instructed to cause one…If something like a time delay occurs this is by design and the CAN should not assume they have done anything wrong and should simply proceed as they normally would.  Thus, it is important not to think but rather “do the algorithms,” you all know well.

Again the CAN should evaluate for further injuries because of persistent or recurrent hypotension:  Often it is best to just go back to the beginning and start with airway and proceed with the ABCs rapidly.  D [disability] was not mentioned earlier but this pt has a GCS of 14 on arrival. EXRS Would be fine with a bedside glucose but other interventions of what some use “The DONT Protocol” [Dextrose, oxygen, naloxone, thiamine] Should be used only with a proper thought process.  The most important blood test would be 10 blood for a fall type and cross match and ordering either or negative, a positive or type specific blood if it is rapidly available [In most hospitals this is a 10 minute process for type Specific provider, type O blood is immediately available at before type and cross match me take up to 45 minutes]. Any blood test that is order must be specifically stated except for electrolytes which means a Na, K, CL, & CO2.  Always order these test based on their clinical simulation and your assessment and this can change anytime during an assessment.  New key information [rhe patient is a brittle diabetic] might be obtained and anyone:, a friend or family member, an old record, paramedic, medic alert tag or PCP might provide this information.  What can always order another blood draw what typically the labs would be ordered from one of the peripheral IV sites.  EXR’s are only able to hear one to possibly three items at a time so speak slowly and you know you are speaking at a proper rate if you can write down what you are requesting.

After appropriate examination, the CAN and should pass an NG tube and an indwelling urinary catheter. Stomach contents are unremarkable and 200 ML of urine returns [A distended bladder may be seen on the FAST] and this could be useful information if a suprapubic urinary catheter was indicated; however, in this patient, there is no blood at the meatus, no pelvic Fx, no perineal bruising or hematoma and no high riding prostate. Rectal tone is normal and there is no frank blood on the stool. Rectal tone is normal.  If any of these were [+] a urethrogramm Would be indicated prior to placement of a Foley catheter. If there’s any question of a urethral injury a suprapubic catheter could be placed especially with a full bladder. It is also  possible that the retrovesical space would be reported as being positive for blood:  [blood is black on sonography].  Remember when performing a FAST study the bladder should be viewed in two planes just like the IVC [hypovolemia off a ventilator would demonstrate a collapsing IVC adjacent or just inferior to the 2nd hepatic vein].

Because of the left lower chest injury and some equivocal left upper quadrant tenderness In the face of Obvious alcohol use [Only revealed if requested], Minimal abdominal findings should be interpreted as a positive because alcohol would impair one’s ability to perceive pain. Even today if no bedside ultrasound were available nor CT scan in a normotensive patient aperitoneal lavagebcould still be performed. AC AN would be required to explain open versus percutaneous techniques, anatomical landmarks and using a supra umbilical technique in a pregnant patient especially if there is a gravity uterus palpated.  This can happen as early as The beginning of the second trimester. If a parent and the other boys were performed in such a case he would not be uncommon for the examiner to reported as equivocally [+] indings so that a CT would be indicated this would show a fractured spleen and a surgical consultation for immediate laparotomy would be mandatory.

THE CAN IS ALWAYS IN CHARGE! THIS IS WHY REHEARSAL IS NEEDED. NONE OF US “SPEAK OUR WORK” AS MUCH AS JUST DO IT! YOU HAVE TO SAY EVERYTHING ON THE ORALS OR IT IS ASSUMED IT WAS NOT DONE!

The CAN should indicate that a physician or a critical care nurse should accompany the patient to the CT scanner and be prepared to infuse further blood…Even if the patient leaves the department normotensive without tachycardia [correct protocol], it is true in the real world physicians rarely have time to accompany our patients for a CT scan…but it is better to emphasize this on an oral stimulation.  Always think would it be better to have an emergency physician with the patient [the ideal person to monitor/treat the patient] and for the purpose of a simulation the answer will always be yes; the same would be true of a physician who is being sued in a court room.  Again if there was any question that the patient was a responder who then had a recurrence of hypertension the patient would just go to the operating room.  The same would be true of a partial responder after looking for other potential sources of hypotension such as pericardial tampaonade:  This diagnosis is not always easy and can be confused with a left tension pneumothorax and the “heart point” Has been documented to improve left tension pneumothorax on bedside ultrasound using the (sternal long axis view the heart moves anterior and posterior in and out of view of the sonographer with a left tension pneumothorax.  Likewise, Gmail a pericardial Tampa nod could be assisted with bedside ultrasound using air bubbles as a form of contrast to confirm the tip of the needle is in the pericardial sac. 

Tintinalli Ed  8 [T8] still discusses the use of an alligator clip attached to a cardiac monitor on one of the V leads and ATLS teaches the use of a 6 inch 18 gauge OTN with a stopcock for repeat aspiration if a pericardiocentesis is going to be performed. It would not be inappropriate for a CAN to perform a pericardiocentesis in this simulation.  New sudden hypotension after a reasonable fluid/blood resuscitation as well as after placement of a left chest tube should actually raise suspicion in support of a Dx of pericardial tamponade.  

G Hutchison: case study copyright 19 89–20 20 the Collman MD and the Collman Institute. All rights reserved. These materials are the property of the Collman Institute Inc., and must be returned at the end of each conference day.  Photocopying or any other means of reproduction by any pbarticipant is strictly forbidden without the expressed written permission of the author and the Collman Institute Inc

[Also remember that classic textbook findings are not always present in real life you’re on a simulation; that range may not be the stand it until late patient has been adequately word recessive Tate it].  Whivh why is this fighting could be present in both TPX and CT [cardiac tamponade].  CANS you must not assume you’re being marked down if a pericardiocentesis is reported as negative; consideration should be given to repositioning the needle or even using a new needle give me a circumstance.The main point is  each time you “divert to thinking about your score” during a simulation, you’ll likely lower the score because it is easier to become distracted and miss a key findings or fail to perform a key intervention.

One of the test scores is for problem-solving and this includes anticipating problems like anticipating the need for further transfusion.  A massive hemothorax would contraindicate the need for a CT scan, however, or If it is clinically suspected or if it is found on bedside ultrasound [the patient would go to the OR.  Simulations don’t tend to follow this pattern because he yet so I instructed to present places that allow them to test all of your abilities.  However, you can never predict what you will find on a multiple trauma victims but you should expect at least three different injuries.  This is a critical value as three organ systems that are injured carries a high mortality rate if the patient is in the first 30 days post injury [I can’t be as high as 100% at three or more organ systems are injured in the first 30 days post injury].  

AMPLIFIEDD OR AMPLE HX;  The amplified history is a version of ATLS’s “AMPLE”, which is just an expansion of the ATLS approach and includes an extra i for Immunizations, the second i for immediate events which is “E” in the AMPLE [E = EVENTS].  The patient’s history should include both surgical Hx and medical conditions and the two D’s…one for doctor or doctors to attend to the patient and one for documents or old records].  

Either approach is reasonable and you should decide on more complex cases to probably use AMPLIFIEDD to avoid missing key information or prevent missing a key consultant. I try to keep this very simple meaning if you have a heart problem, call a heart doctor not an internist [even though in the real world a cardiologist my not be immediately available always choose the best specialist for the problem].  

I have used/presented a lot of “what if’s” scenarios in the simulation and variations on themes to help you realize that these cases can vary quite a bit even though they are not all that complex. 

Sometimes historical data is only available because the EXRs are also scoring you for resource utilization [one of the 8 performance ratings] which means you might find out information only by looking at an old record.  

Again, EXRs have very abbreviated use of language to maximize your management time.  So in reality it is fairly easy to be an EXR  because most of their responses are, “ordered, done, next, anything else?  

This last question bothers a lot of CANs. They will always feel like they left something out if they’re asked this question. It could be a strong clue that an EXR Is it attempting to confirm you’re missing a key action by asking you more than once, (up to three times-like baseball 3 strikes you clearly are “out”), “anything else?”  LOL…The message should be the EXR’s are attempting to maximize your score by giving you extra opportunity do you think because in the real world you take your time and you reason through certain problems I knew even look up data, e.g.,. A dose.  

G Hutchison: case study copyright 19 89–20 20 the Collman MD and the Collman Institute. All rights reserved. These materials are the property of the Collman Institute Inc., and must be returned at the end of each conference day.  Photocopying or any other means of reproduction by any pbarticipant is strictly forbidden without the expressed written permission of the author and the Collman Institute Inc

EXRs  have been so kind as to say, “take a moment and think about it..”….But this is exceedingly rare and EXRs are not ever to guide you through any errors that you may have made.  Any EXR who is giving this much consideration to a CAN he/she is probably concerned his/her statements were errors that mislead a CAN.  EXR’s do you make yours and that is why there are verifiers in The majority of examination rooms.

iCANs have become so stressed it is clear to the EXR the CAN is “over-reacting” often on their first simulation because everyone has a little bit of “nerves.”  It is rare but examiners have been known to tell A CAN to “take a moment” to think.  EXR’s are instructed to be polite and if not it is absolutely due to it acting there were instructed to perform

EXRs are instructed not to provide you with any confirmation that you are making an error or performing a proper procedure this includes their facial expressions. 

However, if an EXR is yelling at you as soon as they politely introduce themselves and sit down and ask, “Are you ready to begin?” If you respond yes, and EXR may be instructed to speak loudly [bordering on yelling at the beginning of the simulation….“the nurses want you in the room right now!” This is an EXR who is instructed to create a stress environment and you should relax and be yourself because nurses are repeatedly screaming for you to come into a room [it is part of our jobs] and your responses should be a normal tone and volume, “I walk in the room and what do I find?”  

This is the same as the GI, the general impression, you should obtain on every patient when you begin a primary survey which you will do on every single simulation. It is best to follow a primary survey-secondary survey approach to most of the cases and eliminate those elements which you don’t require and to learn how to minimize your documentation on the manikin sheet that is provided on the left side of an otherwise a blank sheet of paper for your documentation purposes. 

I will spend time teaching you how to document this sheet because the “minimalist approach” is always best so you can see what you have done and what you have not yet done…When you think of something, in general, you should do it unless it is a sequence issue and clearly out of sequence like a CT before a transfusion.

In the article was published in May 2006 Annals of Emergency Medicine…that references some of my approach to the oral examination…That is the title of the article but I will reprint it on the website for you.

Since the patient is awake, but confused and intoxicated, it is necessary to obtain history from both the patient and the paramedics

I will also stress multiple times that the RECENT past medical history is as important as the immediate events especially as it is in clinical practice. What I mean is that a recent past medical history may have to go back as far as one month with a patient who now has post streptococcal glomerulonephritis [Don’t forget Goodpasture’s syndrome which adds pulmonary hemorrhage after a strep infection].   Nephritogenic strains of Strep clause post strep glomerulonephritis and thus, antibiotics do not preventthis complication!  This has been correctly and incorrectly documented in different additions of the study guide. 

After reviewing all the additions I can tell you there are many errors it’s time for new text is produced and editors do not always catch these errors. In the third edition circa 1986 in the chapter on spider bites and Gila monsters…There’s no discussion about any spider whatsoever!  This is why I have always taught from all the editions.

Now believe it or the recent past medical Hx may have to go back as far as one year with a patient who was on a high dose protocol of steroids and now appears depressed with a viral syndrome, dehydrated [possibly vomiting] and is actually suffering from iatrogenic adrenal insufficiency…This would be classic for a cancer patient but a primary adrenal insufficiency case could also be just a truck driver who forgot his steroids when he went on a long haul..  Anytime in all of the eds of the core content where it says, “most severe, most common, most likely, most feared error, or likely iatrogenic injury…those are the majority of the algorithms they must test in order to certify any physician using oral simulations.  So it is not typical for a patient to have a minor problem and go home on the oral examination although it is possible.  

The certification examination was to cover all of the benign stuff!

The oral examination is to cover all of the things that are life or limb threat Both medically and surgical simulation where are very close to reality!

AMPLIFIEDD HX;

Allergies:  Negative [per patient/paramedics].

M educations:  None.

PM/SHx:  None.

L ast meal:  4 h PTA.

Immediate events:  The patient indicates that he lost control of his motorcycle because the dog ran out in front of him and he crashed into a fence by the side of the road. During the history and physical examination, the patient complains about chest and neck pain and is really requesting pain medication.  [Small intermittent doses of pain medication or appropriate Especially was a patient is established to be “hemodynamically normal”].

F amity, friend[s] or family physician:  None available.

I mmunizations:  UTD per the patient.

E MTs or paramedics:  The paramedics day that Witnesses at this scene indicated that the patient apparently lost control of his motorcycle for no Apparent reason and ran into offense at approximately 50 mph. He was previewing punches at the scene and there was a strong smell of the products of alcoholon his breath

D octor[s] to admit/refer/transfer [e.g., Dr Trauma Surgeon].

D ocuments [old records…now includes state mandated systems for all sorts of medications like opioids]; Could include a prior EKG, cardiac study, or Radiograph/special study

Don’t be discouraged if you get mostly negative responses you get points for asking the questions! There a performance ratings and each one is worth eight points for a total of 64 points.  Yeah or four or five critical actions per case. Critical actions on ACLS/PALS drug doses/drips because they are life-saving in those cases. This is also true for anaphylaxis and anaphylactoid reactions!

G Hutchison: case study copyright 19 89–20 20 the Collman MD and the Collman Institute. All rights reserved. These materials are the property of the Collman Institute Inc., and must be returned at the end of each conference day.  Photocopying or any other means of reproduction by any pbarticipant is strictly forbidden without the expressed written permission of the author and the Collman Institute Inc.

PHYSICAL EXAMINATION [SECONDARY SURVEY]; [often repeated in live oractice]; here these would represent EXR responses. Again a response is only provided if requested by a CAN. Occasionally, if there is a missed positive finding an EXR is allowed at the end to ask, “Anything else?” This [as I will discuss in detail] is a dreaded question because of the timing of when it occurs. It could mean you missed nothing and the EXR is just asking if you have anything else to ask to maximize your score or you missed [potentially] a CA! Don’t be concerned with this now…just understand how the interactions flow and that the EXR has a small visible barrier to keep their work product from your view. ADVICE: If you see a view box it means you probably will be looking at a study…so do not forget this obvious clue…but I think that is no surprise to any of you…however, not all the rooms are organized the same. Even each board has a budget and this could be why they did not have a viewing light or white screen in each room for all the years they have done this. It is a lot of work too! In part, ths is my opinion [which I try to keep to a minimum as I want to give you only objective facts]; I feel the is why some rooms did not have the same set up…they should, in an ideal world all the exam rooms should look the same. This makes the examination even more objective. Many CANs do not like this examination and they have cited every reason you could imagine. I think that it is as close as you could simulate a live interaction because CANs are stressed just enough to cause their true emotions to come to the surface. EXRs are truly concerned about failing a CAN inappropriately. Hence they have verifiers. One board used two in every room for years for this reason. Any EXR errors have to be involved in the scoring…EXRs makes mistakes…it was the number one concern I heard twice a year for the 10 years I trained real EXRs for one board. So they are truly concerned about doing a great job. Just be yourself but do not be fooled into thinking no one rehearsed for this examination. Only a fool would go to the exam without any preparation. Mine was, in part to create a program. It now it a program I have taught formally as one of the two most rigorous programs I have been told were ever created for emergency physicians. I don’t have any tricks. I use the standard content from the core curriculum for residencies….and I have updated cases as many as over a dozen times to ensure they remain classic and updated. I wrote them in a format that should hold up forever…ok back to the EXR responses for the secondary survey. Always rapidly repeat a survey if you think you missed something. I wil show you how you can avoid this issue and how to control stress and fatigue in another section. So to repeat a secondary survey takes secs! just ask “General Impression?” EXR response: “Negative”…means move on…with practice you can do the whole thing in under a minute to find the one thing you missed. EXRS are not allowed to ask, “Do you want to check…[insert any organ system] questions! ok..continue….

GI/LEVEL OF CONSCIOUSNESS:

This is a well developed white male with your sister today and his line on a stretcher and attached to his Longs my board with a rigid collar. He is moaning in pain, slightly confused and anxious.   He has a strong odor of ketones [from EtOH]

HEENT/SCALP/SKULL:

Scalp/skull nl; Face normal. There is minimal erythema of the posterior pharynx.  There is generalized cervical spine tenderness in the midline and posteriorly on the lateral muscle zones. No anterior neck tenderness nor tracheal  deviation.  No step-deformity;  Quality of the voice is normal; tongue is dry.  [Although it is listed in every textbook including ATLS tracheal deviation is often difficult in TPX and in  massive hemothorax].  [Wearing a motorcycle helmet. Full face]

No neck vein distention supine.  No battle sign the raccoon eyes;  No otorrhea nor rhinorrhea

CHEST:  

Diminished breath sounds on the left which improve after placement of the left chest tube. Left rib crepitation/tenderness and left chest subcutaneous emphysema left chest AAL. No flail chest.

COR:  

Rapid heart tones without murmur real or Gallup.Sinus tachycardia on the rhythm strip and cardiac monitor

CHEST; :  

Chest rise/collapse improve after placement of the left chest tube.  I’ll put increases to 750 ML in the secondary survey and the patient has recurrent hypotension.  Remainder of the bony chest including the clavicles AC joints sternum and the remainder of the ribs on the right Anterior and posteriorly in the posterior left ribs are all normal.  The patient complains of left shoulder pain [Referred pain due to an injury spleen and blood inferior to the diaphragm called Kehr’s sign

COR:  

Rapid heart tones without murmur real or Gallup.Sinus tachycardia on the rhythm strip and cardiac monitor

G Hutchison: case study copyright 19 89–20 20 the Collman MD and the Collman Institute. All rights reserved. These materials are the property of the Collman Institute Inc., and must be returned at the end of each conference day.  Photocopying or any other means of reproduction by any pbarticipant is strictly forbidden without the expressed written permission of the author and the Collman Institute Inc

ABDOMEN:  

Direct tenderness in the left upper quadrant but no definitive rebound or guarding. No masses no hepatosplenomegaly. The bow sounds are generally diminished ever and spleen or not palpable.  A bedside ultrasound revealed after the secondary survey is positive for splenic injury With pelvic hemoperitoneum and collapsing inferior vena cava.  The LPLAX VIEW:  And your field hyperdynamic heart with recurrent sinus tachycardia After a brief period hey normotensive blood pressure…Initial responder only-likely class IV hemorrhage by ATLS. 

BACK:  

Normal.

PELVIS/GENITORECTAL

Normal.

EXTREMITIES;  

Multiple abrasions are present without deformity or crepitation.

NEUROLOGICAL;  

The nature of GCS 14; no focal or lateralizing deficits; cardio verse 2 to 12 in tact; pupils equal reactive to light and 4 mm bilaterally. Accommodation  not tested..

LABORATORY;

CBC:

WBC;  11.000/mm3 HGB. 12G/dL.  HCT:  35%

ELECTROLYTES/CHEMISTRIES:

Na;  135 mEq/L K:  3.4 MEq/L. CL:  98 mEq/L

CO2:  22 MEq/L BUN:  17 Mg/dL Cr:  0.9 mg/dL.  

RA-ABG;  pH 7.43;  PO2 89 mmHg;  PCO2:  36 mmHg

TOX:   EtOH:  125 mg/dL;  neg urine drug screen;  Neg for ASA/APAP [quant levels 0.0]

C-Spine Series [5 view]:  Neg except for straightening due to spasm; nl pre-vertebral ST contour.

pCXR:  If done before inserting the chest tube:  Hyperdense left hemothorax c/w left hemothorax…without definite pneumothorax; [Lt subcutaneous emphysema] On left:  fractures of ribs eight and nine on the in the AAL.  Mediastinum nl.

pCXR:  After chest tube:  no deviation of the NG tube and after placement of the left chest tube full expansion of left lung.  Chest tube well positioned.

EKG:  Sinus tachycardia at 125 bpm. Normal intervals and complexes for this rate.

Bedside ultrasound:  as above

Abdominal CT:  Contraindicated

Abdominal series:  Nonspecific me a free air [not indicated since bedside US performed] [If positive for free air it would be Another indication for media laparotomy]

Urinanalysis:  

Hello clear, yellow.

Specific gravity: 1.028; c/w dehydration/intravascular vol loss due to bleeding: negative; sugar negative; Keytone’s: 1+

NOTE:   If the patient had remained hemodynamically normal it is possible that the patient could have had an abdominal CT and it could have shown an encapsulated splenic lacerations that could’ve been managed to conservatively; that is another possible outcome for the simulation If there was no massive hemothorax mandating operative intervention.  

CAs:  Critical actions I always list as possible/potential critical actions;  It’s case can be designed by the board says that it follows different pathways and the board did where is that this concept in the 1990s to avoid or prevent cheating on this examination.

1.  Apply oxygen to create a saturation of at least 95% and perform the ABC’s..the typical high flow tight fitting mask is fine at 12-15L/min if you ar not immediately intubating a patient. Typically, if an EXR is confident in your presentation as soon as you say, “I intubate with an 8.0 mm tube”…the EXR responds, “done.” They keep it simple so you can show them all you are capable of and the goal is to maximize your score. On this case an intubation would not be required at the beginning but it would be needed once you decide the patient is going to the OR…so it would be a CA for this case. Always assume they expect you to get the patient ready for the consultant..in this case…the O.R. Intubation would be expected; many would intubate a motorcycle victim early for many reasons. which we can discuss either in a forum or I will present this as well in another discussion.

2.  Helmet removal [2 person technique] and C-spine evaluation [CT neck could have been a CA]

3.  Initiate 2 u transfusion after 2 L isotonic LR infusion; f/u transfusion/possible auto transfusion

4.  Left chest tube insertion with post chest tube/NG tube portable chest x-ray.

5.  Bedside US:  EFAST/I don’t have a clean normal abdominal CT scan

6.  Emergency trauma surgeon evaluation IDear Way in the first 20 minutes post arrival

7.  To O.R. [massive hemothorax]; possible post-pericardiocentesis.

PATHOPHYSIOLOGY QUESTIONS:

Q:  What does subcutaneous emphysema indicate in a patient with blunt  chest trauma?

A:  It can develop when air from the lung parenchyma that gained access through the chest wall [ or via the same mechanism from a tracheobronchial injury].   It maybe occur after severe rib fracture via a chest wall defect or after injury to the esophagus [Borhaave Syndrome].  

Q:  Are there still applications for peritoneal lavage in the adult patient with blunt abdominal trauma.  

A:  With the advent of bedside ultrasound the indications are significantly diminished.  However, if bedside ultrasound were not immediately available nor CT of the abdomen indicated due to hypotension, I.e., a hemodynamically unstable patient w/ negative plain films for free air… this procedure could still give a quick answer for an indication for emergency  laparotomy.  It is still a procedure in protocols for ectopic pregnancy.  In a patient in later stages of pregnancy procedure would have to be done superior to the fungus.  There are no real absolute country indications to this procedure it’s just that we now have a noninvasive method that is generally widely available, i.e. bedside ultrasound.  

Q:  Based on the formula for the volume of a cylinder can a massive hemorrhage of the thigh occur without a significant change the diameter of the thigh?

A: Yes!  This was presented well in 1985 Bears text Emergency Management of Pediatric Trauma. The diameter of a thigh or cylinder does not have to change for it to fill with a large volume of fluid, i.e., blood. I created an illustration for this very injury in mid-shaft fracture of the femur so this is “old news”.  In the very young or elderly hemodynamic instability can be hidden or late [as with a hypervolemic pregnant patient..if they show shock..it is always late shock] The risk for sudden death is much greater when there is a class IV hemorrhage [40% blood loss].  The approach in many hospitals now is to have a team who supply multiple elements of the blood in proper proportions to improve outcomes…but still these patients carry a high mortality rate. Many patients died from missed bilateral femur shaft fracture’s.  In some cases they were “hidden by a MAST suit”…but anyone then knew of this risk when it was popular. Yet patients still died from this “miss.” If a large vessel is lacerated a life-saving maneuver might be to amputate the limb. That is still true today.

End of case G Hutchinson…if you have any questions or comments please send them to me…Much more to come. This is a new site and I hope the one I will continue. My teaching life was, in part, interrupted by some crises that happen to all…several ill family members…I apologize I was away so long. I have stated the details in prior posts but that part of my life is behind me and I hope you will continue to use my services. Thank you for keeping me motivated! I am going to publish this page to get it out for you who are taking your exams this fall..but I can begin rehearsing soon…i am just moving finally…have not made that decision but packed up the entire 3 decades of my teaching life recently! I will be writing constantly. I wil also add illustrations. I hope you enjoy them. Many I have printed for sale because they are great reminders for you and stage and they tell the world we save lives!…DDC.  

Rate this case Study! Send Doctor Collman a message. He appreciates your feedback. These are simulation materials that were used to train Examiners and for live oral emergency test examinations.

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Published by DrC

Clinical Emergency Physician Faculty for Midwestern University EM Author/Educator/Medical Ilustrator Expertise: EM Pathophysiology and healthy physiology [both pediatric/adult] Designer of a silicone membrane ECMO Trained ⅓ of the world’s EPs for EM board certification Trained Oral Examiners for a decade: the Board of Certification in Emergency Medicine [5000 original members...now the second largest EM group in the United States]; he was a compensated consultant for that and numerous other emergency medicine organizations. All of his presentations have Co-sponsored AMA/ACEP category 1 CME ACCME accreditation through thecAAPS, National and The Fl Chapter of ACEP and The Fl Medical Association since 1989. Publisher of numerous EM manuals, and educational materials [all items were have copyrighted notices and have been sold sold by the ACEZp Bookstore]; all authored by Dr Collman: 2 Vol program syllabus of thousands of Q/As and pathophysiology discussions of all chapters from eds 3-8 of “The Study Guide” [All chapters of the core content knowledge for completion of an emergency medicine residency]; teachs Resususcitation, CV Emergencies, Pulmonary Emergencies, The EKG lab [the 60 most important EKGs/management; Truama Emergencies, Pain Mgmt, Orthopedic Emergencies, Toxicology [Toxins and Antidotes, HEENT Emergies, Environmental Emergencies, Pediatric Emergencies [500 Q/As], HIV/AIDs-Infectious Diseases, Emergencies, Rhematologic Emergencies, Neurologic Emergencies, Acid-Base/ABG Presentation, Dermatological Emergencies, CT/POCUS [point of care ultrasound], Bariatric Emergencies, Endocrine Emergencies. Dr Collman is endorse by virtual all of his programs participants [13,000+] Examples: Dr James SULLIVAN MD DABEM; and others program participants describe Dr Collman as a “National Treasure” Others: “He is the guru of EM”. [Jerry Solot DO, an EM Director for a Pittsburgh Community Hospital [and one of his private tutor clients] Others call me “The Boca University of Medicine”[BUM] and know I grandfathered into EM after completing a rotating Gen Surg Internship at UCLA School of Medicine [June 1981]. I was offered a directorship position at age 25, the contract to Illustrate “Emergency Management of Pediatric Trauma” [author:Thom Mayor MD FACEP] published by WB Saunders Dr Collman provides psychological support to his program attendees...many chose him to be their permanent career mentor and return annually to his live interactive conferences. Dr Collman has designed computer-based programming to numerous organizations in ACLS algorithms [Univ of Pisstburgh] He provides Interactive grand rounds as Case Simulations by invitation: He designed the an 8-h Visual Stimuli Presentation for Johns Hopkins Dept of EM [their board prep program;a second 8 hr presentation “The Genitourinary System-a Comprehensive 8-hour Review”; he teaches each program Johns Hopkins University. He trained Examiners for the BCEM [AAPS] Atlanta GA: presented a combined certification review [both certification part I/orals] numerous time in Atlanta, Hawaii, Lake Tahoe, and Orlando, Fl 1991-1996. He created their entire bard exam [part I and Oral Examination and a computer-operated Visual Examination [2 Versions] in 1996. This included 700 certification test items and 25 Oral Examination Live Test Simulations as well as trained their AAPS [BCEM Examiners twice a year for 10 years [throughout the 1990s] Texts Authored Editor in Chief 4th-7th Ed of: “Pearls of Wisdom in Emergency Medicine [7 eds] and 35 Cds [33 are critical analysis of the 52 OBT Live CD set: audio recording made Live at Conference [cost $1515.00 (Oral Board Case studies)+ ASA/APAP toxicology CDs [each is 1 hour w/manual purchase price $65.00 for each + “CT Video: CT for the Emergency Physician”. Videotaped Live in Boca Raton, FL by Pear Productions; director and producer: Clayton Pereira. Contributors: Kris, Katie, Ryan Collman Barbara Schwartz [voiceover] Original music: Kris Collman on Acoustic Guitar Chapter Voiceovers: Katie and Ryan Collman Katie and Ryan: Pediaric calculation presentation [at ages 6 and 4 they presented a 2 h lecture for 2 years at 6 conferences to every participant of “The 8-Day Interactive Review!” “Dwight Collman MD DABEM DABFM Provides the most rigorous CME Education”...documented by EM News and EMRA [in 2002 ranked Dr Collman’s EM 8-Day Interactive Review! with the top 8 University or top ACEP chapter programs [an independent study they published for all of America’s Emergency Medicine Residents preparing for their board certification examinations. 2009 Jan Issue EM News Editor-in-chief ranked Dr Collman as the “premier educator for board preparation in the US” Core Competencies: Bedside Clinical Instructor all EM Medicine Clinical assessment/training EPs in all EM Procedures [over 90 procedures] Core competency: illustrates human Anatomy as it pertains to EM/EM procedures [he does this Live and his clients request to keep his illustrations] Dr Collman edited Emergency Management of Pediatric Trauma [while he illustrated this First-Ever Text devoted to Pediatric Trauma; he spent 2 years creating the illustrations for this text [983-1985 and they were reproduced and resold bynthe publisher and appear in the Pediatric Trauma Capter of The Text: The Clinical Practice of Emergency Medicine” Ed 1., author Ann Lattimer-Harwood-Nuss [now Professor Emeritus, retired]. Completed a Fellowship in Gen Anesthesia: University of Utah School of Medicine Awarded 5 specialty rotations [mentor ship programs in medical school:ICU President: Collman Institute Inc [a Fl S-Corp] 1994-2007 and 2018 to present. Clinical practice x 40 Yrs ABEM certification Life Fellow Am Board of Forensic Examiners Trains EPs in triage/emergency Pt care/documentation to mitigate litigation risk Has been awarded contracts [per physician] from over 400 US Hospitals Trains EPs from every branch of the US Military since 1989 -first group I traine included the CO of the Portsmouth, Va Naval residency [Michael Gonzalez MD FACEP who officially made the Oral Board Tutorial! As mandatory education to graduate his residency program in 1989. I am a “trainer-educator, author, medical Illustrator” Additional self funded missionary physician to Ukraine, Carribean, S America since 1987...[ongoing] Supplied Orphanage in Kherson, Ukraine with new supplies $5,000. I have treated college students at no cost since the 1990s Additional skills/competencies: Documentation [chart review consultatnt], Test item Writer [wrote the entire certification partI/part II examinations in 1996 Teach/train using interactivity/I teach the statistical/mathematical precognitive approach to physicians for pediatric IV fluid protocols for resuscitation, 3 forms of dehydration, burn fluid calculations + formula for airway [pulmonary burns] 52 simulations in 5 days; the role of the CANs/EXRs; I have a program syllabus for both of my CME programs Program author/presenter: “The Clinical Documentation If the Emergency Medicine Hospital Chart”, a 2-Day program conducted in Park City, Utah [1992s] As a Forensic Examiner he has reviewed and consulted emergency Physician defendants [approx 300 cases over 25 years] He has presented to children at the local middle schools for Spanish River Christian School Three presentations: a “suturing practical in which young students sutured wounds created on Pigs feet’s, a Gastrointestinal presentation for the 4th grade; “what is an X-ray” lecture for the entire school; Dr Collman donated funds and participated in annual fundraising events at Spanish River School for 8myears]; he created background scenes for both Spanish River Christian School and recreated the Parthenon for a Greek Play for the second Grade at Westminster Academy in Ft Lauderdale. He greatest achievement is his role as a single father and he has watched his aforementioned adult children all have successful marriages: Kristopher David Collman will soon be an MD., JD; Katie is a school teacher since age 19 [retired after 11 years at Bethany Christian School as a primary school teacher 1st/3rd grade]; Katie has a successful site on Etsy and has been an annual missionary all 4 years of her undergraduate education to a Bolivian Orphanahe. She is a mother and married a minister. She has a son who she devotes her days but will likely return to education and she is an excellent artist and gifted/enjoys creating personalized crafts [her website on Etsy:”The Black Pearl” Ryan David Collman has completed a BA, 2 masters and now is again on his 4th fully funded Scolarship at Edinburgh University for his PHD in Christian Studies; he was able to and did Marry Kristopher to Amanda When Ryan was 22 year-old! He his also a self-trained painter and has been married to his wife Lauren who was the Salutatorian of their high School. All three have chosen service-oriented lives and qualify as the brilliant, talented and loyal loving spouse [both sons married brilliant accountants who are amazing mothers. Amanda is also a gifted artist. I call these three ladies “the sisters and they support each other no matter how far they live apart. Ryan and Lauren have e tensively travelled Western Europe with their daughter and currently since November they have a newborn son;his toddler sister attends school 3 days a week and reads her baby brother and sings. My eldest grandchild is in her 2nd grade year and she too has a younger baby brother and she is like her cousins happy, brilliant and all are healthy and thriving! They are my greatest joy! I don’t list their names because I want them to have their privacy/security. I did have to take a break from teaching to care for my parents who are both deceased as are two of my brothers; my mother was the owner/operator of Lil Audreys Health Spa USa and received a Lifetime Achievement Award from the State of Utah fir her work in keeping 40,000 women in Utah in shape/for helping thousands lose weight; many lost up to 100 lbs. Many were Lifetime members. My father, Joel Collman was an electrical/mechanical engineer by training, a brilliant man who became a designer for electrolysis on the first United States Nuclear Submarine then moved us from my birthplace [Huntington, NY] to Utah in 1959. Where he designed and built the rocket motors for our countries ICBMs [Miniteman I, II, and III series] and may have held as many as 90 patents; when he irked he then worked with mom as her accountant/collections Manager/he reengineered her Healthspa [a school they purchased]. my mother exercised and ate a healthy balanced diet was known by every woman in the State of Utah, often worked tirelessly for 12 h a day; never took a “sick day from medical illness.” I have 2 remaining siblings who live in Utah. I hope to one day reopen the “SPA” as a pvt medical facility for Antiaging and regenerative medicine while I continue all of my other above activities. Because of my mother I followed her advice to do everything in moderation, to protect my skin, and to sing as she did and to remember that your “true wealth is your health”. She lived by such rules and I would be nothing without her wisdom and love forvservice to others...I learned how to be a servant as a physician from my mother...I learned how to make rocket fuel from dad! I’m actively seeking new teaching opportunities and clinical practice as a faculty member or a clinical emergency physician while Incontinue to write and teach as many EPs andAPPs. I also hope to marry and have two more children.

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