<img src="media/title_medium.png">
''Learning objectives:''
* Develop, and demonstrate, analytical skills for integrate research evidence into decision making in healthcare.
* Design approaches to assist patients and the general public make sense of the huge variety of medical information available; improve patient and the general public’s understanding of the implications, and applications, of medical research; and, counter the spread of disinformation around medical research.
* Describe approaches to engaging patients in the decision-making process, using shared decision making, including explaining the evidence and integrating their preferences.
---
(link-undo:"Go Back")
---(b4r:"dotted")+(b4r-size:2)+(b4r-colour:navy)+(text-style:"bold","expand")[Scenario 1: Janet]
(text-style:"bold")[Congratulations Dr. $playerlastname on finishing medical school! 🎉👏]
It is your first day on your first rotation at a major metropolitan hospital. You are working with a busy general surgical team.
You've just finished your morning round (and the boss bought you a coffee! What a treat!). After a moment of daydreaming, imagining that you might see a patient with ''$playerfavdisease'', you sit to start on your innumerable jobs.
Suddenly, you feel your pager buzzing wildly. It has begun.
You take a deep breath and reach down.
---
[[Pick up your pager->1-readpage]]
---Your registrar is currently scrubbed in theatre. The scout nurse takes down your details and says she will call once available.
[[Go see the patient->1-firstmeet]]
[[Call Ashleigh, Janet's bedside nurse->1-callnurse]]
---<img src="media/janetbedside.jpeg">
Janet is resting in a single-bed bay when you arrive.
You see ''Matilda'', a nearby nurse, who informs you that Ashleigh (Janet's regular nurse) is on break. Ashleigh was concerned about a new cough and increased respiratory rate. Matilda has not looked after Janet before.
You don appropriate PPE, enter Janet's area, close the door, and sanitise your hands.
---
[[Continue->1-initialreview]]
---(link-undo:"Go back")
---
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(text-style:"bold","underline")[💻 Research Hub 🏥]
|==|
---
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<a href="https://go.openathens.net/redirector/unimelb.edu.au?url=http%3A%2F%2Fwww.uptodate.com%2Fonline" target="_blank" rel="noopener"><img src="media/logo_uptodate.png"></a>
|==|
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<a href="https://go.openathens.net/redirector/unimelb.edu.au?url=https%3A%2F%2Ftgldcdp.tg.org.au%2FetgAccess" target="_blank" rel="noopener"><img src="media/logo_etg.png"></a>
|==|
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<a href="https://go.openathens.net/redirector/unimelb.edu.au?url=https%3A%2F%2Fwww.mimsonline.com.au%2FSearch%2FSearch.aspx" target="_blank" rel="noopener"><img src="media/logo_mims.png"></a>
|==|
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<a href="https://go.openathens.net/redirector/unimelb.edu.au?url=https%3A%2F%2Famhonline.amh.net.au" target="_blank" rel="noopener"><img src="media/logo_amh.png"></a>
|==|
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<a href="https://go.openathens.net/redirector/unimelb.edu.au?url=https%3A%2F%2Fwww.cochranelibrary.com%2Fadvanced-search" target="_blank" rel="noopener"><img src="media/logo_cochrane.png"></a>
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<a href="https://scholar.google.com.au/" target="_blank" rel="noopener"><img src="media/logo_googlescholar.png"></a>
|==|
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<a href="https://go.openathens.net/redirector/unimelb.edu.au?url=http%3A%2F%2Fovidsp.ovid.com%2Fovidweb.cgi%3FT%3DJS%26NEWS%3Dn%26CSC%3DY%26PAGE%3Dmain%26D%3Dppez" target="_blank" rel="noopener"><img src="media/logo_ovid.png"></a>
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<a href="https://go.openathens.net/redirector/unimelb.edu.au?url=https%3A%2F%2Fwww.clinicalkey.com.au%2F" target="_blank" rel="noopener"><img src="media/logo_clinicalkey.png"></a>
|==|
---
(link-undo:"Go back")
---Ashleigh says that she's noticed that Janet looks more short of breath in the past hour with new onset cough. She took a set of vital signs as follows:
* HR:105
* RR:30
* BP:160/90
* SpO2:87%
* Temp=37.6 C
She started Janet on some supplemental oxygen via low flow nasal prongs (1L). This inscreased her SpO2 to 93%, but Janet's respiratory rate has remained high.
She is keen for you to review Janet as soon as possible.
---
[[Go see the patient->1-firstmeet]]
---(b4r:"solid","none")+(b4r-colour:white)[(text-colour:green)+(background:black)[KILMORE 9374812 WARD 3 BED 12 INCREASED RR AND COUGH. PLEASE REVIEW. ASHLEIGH X97418.]]
It was a fast ward round and you don't recognise the name. You cross-check with your handover list.
---
[[Check your list->1-caseoverview]]
---<img src="media/scenario1_full.jpg">
//[''Janet Kilmore'' | UR 947834 | 93yoF. Witnessed fall nil headstrike -> R #NOF -> D3 post R hip hemiarthroplasty. PHx HTN, HFpEF, COPD, Alzheimers dementia.]//
---
You've got lots of other jobs on your list. There are several patients pending discharge, and the ANUM is keen to free beds as ED is currently bedblocked. You also need to get notes faxed from another hospital, and speak with PACS (image transfer) about getting MRI images uploaded onto your system. Your registrars and consultants are currently in theatre.
''What do you do next?''
---
[[Review Janet's chart->1-chartreview]]
[[Go see Janet->1-firstmeet]]
[[Call back Janet's bedside nurse, Ashleigh->1-callnurse]]
[[Call your registrar->1-CallReg]]
[[Work on other jobs-->1-otherjobs]]
---You start to finalise discharge scripts but feel uncomfortable leaving Janet unseen. You decide to go check on her instead.
[[Go see Janet->1-firstmeet]]
---You begin by observing Janet and her surroundings.
Janet is a frail, elderly woman occasionally muttering to herself. A falls risk sign is posted on the wall. She is wearing nasal prongs with 1L supplemental oxygen running. She has an oversized, faded ''$playerfavcolour'' handbag at the bedside, and you can see a box of chocolate biscuits dwelling within.
Your stomach starts to rumble, and you take a moment to dream of shamelessly eating those biscuits. However, you restrain yourself and continue your general inspection.
There is a card that says 'Get Well Soon' at her bedside. Her breakfast tray is nearby, but it does not look like Janet has eaten much today.
''What do you do next? ''
---
[[Go review Janet's medical chart->1-chartreview]]
[[Take a history->1-initialhistory]]
[[Perform a physical examination->1-physicalexam]]
[[Order some investigations->1-ddx]]
[[Chart medications-->1-ddx]]
---You begin by asking Janet how she is going.
She looks awkwardly at you. Her work of breathing mildly increases as she leans forward and lets out a powerful, hacking series of wet coughs. Then she rests backwards.
After an uncomfortably long pause, Janet proclaims in a deep, raspy, and unforgettable voice,
(text-style:"bold")["WHAT'S THAT, LOVE? NEED MY HEARING AIDS"]
You pause and get ready to do some searching.
---
[[Search for her hearing aids->1-hearingaid]]
---You step forward to perform a general examination of Janet.
''General appearance:'' Elderly woman with 1L Supp O2 via NP lying in bed at ~30 degrees. Appears tired. IV access R cubital fossa, nil infusions running. Occasionally muttering to herself. Wounds: postoperative dressing over R) hip. Nil strikethrough.
''Lungs:'' Difficult examination. Pt complains of ++ pain when attempting to lean forward. Anterolaterally: widespread crackles heard bilaterally. ? some reduced air entry laterally?
''Heart:'' Mild tachycardia (100-110bpm) with regular rhythm. Dual heart sounds, nil added.
''Abdomen:'' Soft, non tender. Margin of R) hip dressing noted with nil strikethrough.
''Legs:'' Pitting oedema to ankles bilaterally. Nil erythema. You try to squeeze her calves and she says 'stop that!'.
''What do you do next?''
---
[[Try to reassess her lungs->1-reassesslungs]]
[[Re-examine her legs->1-reassesslegs]]
[[Remove the wound dressing over her R) hip->1-removedressing]]
[[Proceed to order some investigations->1-ddx]]
---You do several laps of the ward and ask the ANUM for help, but can't seem to find Janet's chart. Alas.
''What do you do next?''
---
[[Go take a history->1-initialhistory]]
[[Perform a physical exam->1-physicalexam]]
[[Order some investigations->1-ddx]]
---<img src="media/titlefull.png" alt="title screen">
---
(b4r:"dashed")+(b4r-size:2)+(b4r-colour:(hsl:0,0.8039,0.5,0.5),(hsl:0,0.8039,0.5,0.5),(hsl:0,0.8039,0.5,0.55),(hsl:0,0.8039,0.5,0.55))
[(if:$userentrycount is 1)[[[Start->Overview]]](else-if:$userentrycount is 0)[[[Start->PlayerInfo]]]]
(text-colour:grey)+(text-style:"italic","subscript")[Version 3 | Last updated: 10 April 2024.]
---
(text-style:"subscript")+(text-colour:(hsl:0,0,0.5333,0.65))[I love bugs and glitches!🐞👾🔥 Email me for instant 💯 points - aiden.varan@gmail.com.]''About''
=|=
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<img src="media/logo_unimelb.png">
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|==|
<img src="media/title_small.png"> was developed in 2021 by the Melbourne School of Population and Global Health (MSPGH), University of Melbourne, to enhance learning on evidence-based medicine in practice for soon-to-be junior doctors. It was revised in 2022 with minor edits in 2024.
(text-style:"bold","underline")[Lead Developer:]
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<img src="media/aidenprofile.png">
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|==|
''Dr. Aiden Varan, MD(Distinct), MPH, BSc(Hons)''
Paediatric Registrar, Victorian Basic Paediatric Training Consortium
University of Melbourne MD Graduate (Class of 2019)
(text-style:"bold","underline")[Project Supervision:]
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<img src="media/rosemaryprofile.png">
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|==|
''Prof. Rosemary McKenzie, PhD, MPH, BA, PG Dip Hlth Prom''
Director of Teaching and Learning | Melbourne School of Population & Global Health
Deputy Director | Centre for Health Policy
University of Melbourne
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<img src="media/kenprofile.png">
=|=
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|==|
''A/Prof. Ken Winkel, PhD, MBBS, BMedSci''
Senior Research Fellow | Melbourne School of Population & Global Health
University of Melbourne
(text-style:"bold","underline")[Beta testing for Version 1 (2021):]
=|=
<img src="media/kathyprofile.png">
=|=
=|=
|==|
''Kathy Zhang''
Former MD/MPH Student (MD4 2021), Faculty of Medicine, Dentistry and Health Sciences
University of Melbourne
This interactive adventure was developed using <a href="https://twinery.org" target="_blank" rel="noopener">Twine</a> with Harlowe 3.2.1. Stock photos obtained with relevant permissions.
Feedback/comments/issues to:
<a href="mailto:aiden.varan@gmail.com?subject=EBMQuest Feedback: &">aiden.varan@gmail.com</a>
---
(link-undo:"Go Back")
---''Choose your scenario''
=|=
[[<img src="media/scenario1a_card.png">
Janet
(Pt. 1)->1-welcome]]
=|=
(if:$complete1a is true)[[[<img src="media/scenario1b_card.png">
Janet
(Pt. 2)->1-eveningcover]]](else:)[<img src="media/scenario1b_card_locked.png">
Janet
(Pt. 2)]
=|=
(if:$complete1b is true)[[[<img src="media/scenario2_card.png">
Robert->2-welcome]]](else:)[<img src="media/scenario2_card_locked.png">
Robert]
|==|
---
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(color:purple)[[[Title Screen->TitleScreen]]]
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(color:purple)[[[Overview->Overview]]]
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(color:purple)[[[About->About]]]
|==|
---
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(if:$complete1a is true and $complete1b is true)[(text-colour:red)+(text-style:"buoy")[[[Finish->postsummary]]]](else:)[(color:purple)[[[Finish->postsummary]]]]
=|=
=|=
(text-colour:grey)[(link: "🔙 Restart")[(confirm: "Are you sure?")[(reload:)]]]
|==|
(b4r:"dotted")+(b4r-size:2)+(b4r-colour:navy)+(text-style:"bold","expand")[Scenario 2: Robert]
<img src="media/outsideED.jpeg">
You've just started your rotation in Emergency Medicine at a rural hospital.
It's an exciting but daunting chance to get 'hands on' into clinical practice. You never know what you might see. Maybe, just maybe, you will diagnose a case of ''$playerfavdisease'' and be the envy of all your colleagues.
Time to start seeing patients!
---
[[Check the triage board->2-triageboard]]
---After an inordinately long and awkward search through her bedside cupboard, you find a small clip box containing two hearing aids belonging to Janet. You try to turn these on, but the batteries are dead. After pleading with your ward clerk, you obtain new batteries.
Finally, Janet has her hearing aids in and you can take a more extensive history.
---
[[Take a full history->1-fullhx]]
---You attempt to take a more detailed history.
''HOPC''
Janet tells you that she had a fall at the nursing home a few days ago. She lost her balance but can't remember exactly what happened. She doesn't think that she hit her head. She had a lot of pain in her right hip afterwards. She tried to get up but found it too painful. She called out for help and one of the nurses found her on the floor.
She isn't exactly sure what happened afterwards. She got to the hospital and had a lot of pain. The doctor downstairs did an injection in her groin that helped with the pain. Other doctors said she broke her hip and needed an operation. Lots of people have been trying to get her walk but she has felt really tired.
Today she's felt a bit short of breath and the nurses started have been giving her oxygen. That has helped a little bit.
She has been coughing quite a bit since yesterday evening. She occasionally has a cough at home. However, it tends to be dry or, if productive, white. Now, she is bringing up yellow-green phlegm.
''PMHx''
When asked about her past medical history, Janet says she 'has a few health issues' and 'takes lots of tablets' but isn't sure of their names. She says the nurses give them and she swallows them. She confirms that she has a significant smoking history, proclaiming proudly that 'Been smoking since I was 16, love!'. She doesn't use any oxygen at home.
You try to ask additional questions but Janet says that she's feeling too tired and sick of giving the same answers over and over.
What do you want to do next?
---
[[Perform a physical examination->1-physicalexam]]
[[Order some investigations->1-ddx]]
---In order to rationally order investigations and commence a management plan, you need to decide on your primary differential diagnosis.
''What is your primary differential diagnosis for Janet's current presentation? ''
---
[[DVT/PE->1-dvtpe]]
[[Hospital-acquired pneumonia->1-hap]]
[[Post-operative pain->1-postoppain]]
[[Delirium->1-delirium]]
[[Anxiety->1-Anxiety]]
[[Acute exacerbation of heart failure (HFpEF)->1-HFpEF]]
[[Normal post-operative course; nil acute issues->1-noproblems]]
---''Overview''
<img src="media/stethbook.jpeg">
---
[[Learning Objectives->LearningObjectives]]
[[About->About]]
---
(text-style:"buoy")+(text-colour:red)[''Greetings soon-to-be Dr. $playerfirstname $playerlastname!'']
''EBMQuest!'' is an interactive self-paced module written in a 'choose your own adventure' style.
It aims to help soon-to-be junior doctors explore the implementation of evidence-based medicine in their practice.
''The module is divided into two scenarios: ''
1. Janet (a ward-based "long case" in two chapters);
2. Robert (an ED-based "short case" scenario).
''After reviewing all scenarios, click on //Finish// to review post-module information. ''
(text-colour:yellow)[''This is NOT a situational judgment test (SJT)''].
Feel free to explore different avenues and decisions in each scenario. Some will lead to dead ends, others to unexpected outcomes. There are no penalties.
<img src="media/quicklinks.png">
Go forth!
---
[[Continue->ChooseScenario]]
---
(if:visits >= 1)[(set: $userentrycount to 1)](if:$playerfirstname is "Easter" and $playerlastname is "Egg")[(set:$complete1a to true)(set:$complete1b to true)]You call out for Matilda to give a hand. With Matilda's skilled assistance supporting Janet forward, you manage to have a better listen of Janet's chest and back.
You confirm scattered coarse crepitations bilaterally and reduced basal air entry. You also note some focal crepitations on the left side.
You want to work out whether Janet has a pleural effusion, but Matilda can only hold Janet in place for a few more seconds.
''What of the following findings or manoeuvres would be MOST helpful for you to distinguish whether Janet has a pleural effusion? ''
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: Physical Examination for Pleural Effusion->EBM-respexam]]]
---
[[Auscultate for crackles-->1-lungcrackles]]
[[Auscultate for a pleural friction rub-->1-lungfrictionrib]]
[[Percuss for basal dullness->1-lungdullpercuss]]
---You attempt to once again examine Janet's legs.
You confirm that she has pitting oedema to her ankles bilaterally, and nil LL erythema. Her feet are quite cool and her nails are unkempt.
With a more gentle technique, you also confirm that she does not have calf tenderness - you had just surprised her last time!
---
[[Order some investigations->1-ddx]]
[[Chart some medications->1-ddx]]
---You move to start unveiling the wound dressing when Ashleigh returns from break and peeks her head in.
Cautiously, she asks, "Why are you removing the sterile dressing?".
You immediately stop and realise this will yield little clinical benefit, as the dressing is clean and dry. You thank Ashleigh and take a moment to stop and breathe.
What would you like to do next?
---
[[Order some investigations->1-ddx]]
[[Chart some medications->1-ddx]]
---You hear crackles widespread, with a possible focus on the left mid side of the chest. It's hard to tell if there are more or less crackles in teh lung bases.
Janet slumps back onto the bed exhausted.
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: Physical Examination for Pleural Effusion->EBM-respexam]]]
//Wong et al. (2009), //
"Discontinuous sounds or crackles may be heard in pleural effusion as distal airways collapsed from the previous exhalation abruptly open during inspiration."
In this clinial review, crackles on auscultation were associated with the following parameters for a pleural effusion:
=|=
Positive LR (LR+)
1.5 (1.1-2.0)
=|=
Negative LR (LR-)
0.71 (0.52-0.97)
|==|
''What would you like to do next?''
---
[[Order some investigations->1-ddx]]
[[Prescribe some treatment->1-ddx]]
---You listen hard for a possible friction rub during inspiration and expiration, but can't be sure that you've heard one.
Janet slumps back onto the bed exhausted.
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: Physical Examination for Pleural Effusion->EBM-respexam]]]
//Wong et al. (2009), //
"A pleural rub may be audible in inspiration and expiration, reflecting the presence of inflammation, such as rheumatic pleural effusion, adjacent to the area of the finding."
In this clinial review, a pleural friction rub was associated with the following parameters for a pleural effusion:
=|=
Positive LR (LR+)
3.9 (0.80-18.7)
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Negative LR (LR-)
0.96 (0.90-1.0)
|==|
''What would you like to do next?''
---
[[Order some investigations->1-ddx]]
[[Prescribe some treatment->1-ddx]]
--- You carefully percuss and notice a sharp demarcation at the lung bases bilaterally and symmetrically. One might describe your findings as 'stony dullness'.
Janet slumps back onto the bed exhausted.
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: Physical Examination for Pleural Effusion->EBM-respexam]]]
//Wong et al. (2009), //
"The clinician should firmly place the second or third finger of the nondominant hand horizontally against the patient’s posterior chest wall between the ribs. The second or third finger of the dominant hand should be slightly flexed and using the fingertips, the clinician should tap the distal interphalangeal joint of the firmly placed finger of the nondominant hand. Starting at the apices and progressing down to the bases, the left and right hemithoraces should be compared at equal horizontal planes. A chest in normal condition should sound equally resonant on both sides... pleural effusion will produce decreased resonance"
In this clinial review, dullness to percussion was associated with the following parameters for a pleural effusion:
=|=
Positive LR (LR+)
8.7 (2.2-33.8)
=|=
Negative LR (LR-)
0.31 (0.03-3.3)
|==|
''What would you like to do next?''
---
[[Order some investigations->1-ddx]]
[[Prescribe some treatment->1-ddx]]
---(set: $DDx1 to "DVT/PE")
You decide that Janet could have a DVT/PE. She is day 3 post-op with limited mobility, and is tachycardic and tachypnoeic requiring supplemental oxygen. You don't know of any history of cancer or DVTs in the past.
You are keen to order a CTPA to assess for any pulmonary emboli. However, when you attempt to place the request in your electronic medical record system, it requires entry of a Wells score.
<a href="https://www.mdcalc.com/wells-criteria-pulmonary-embolism" target="_blank" rel="noopener">''Calculate Janet's Wells Score''</a>
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: Clinical prediction rules for pulmonary embolism ->EBM-PE]]]
What is Janet's Wells score?
(input-box:2bind $wellsscore,"X==========",1,"")
---
[[Place your electronic order->1-dvtpe-placeorder]]
---(set: $DDx1 to "postoppain")
You decide that Janet's main problem is pain after her surgery. You chart 5-10mg Endone (oxycodone IR) PRN q4hr, which will have the added benefit of reducing her respiratory rate.
You handover the plan to Ashleigh and return to your other busy ward jobs. You get swept up and forget to check for responsiveness
When your registrar finishes the case and calls to check in, you review your findings and plan. On hearing Janet's vital signs, your registrar is concerned. She decides to meet you at Janet's bedside immediately.
You hang up, and prepare to head back to the bedside.
---
[[Continue->gameover]]
---(set: $DDx1 to "delirium")
You decide that Janet's main problem is delirium. Clearly she didn't recognise you and was uncooperative to examine, and her lack of a textbook history sinched the diagnosis.
You prescribe some haloperidol to help settle Janet and return to your other busy ward jobs.
An hour later, you get an urgent call from Ashleigh. Unfortunately, Janet has reacted very poorly to the antipsychotic and has become more agitated. She has jumped out of bed and sustained another fall. She needs you to urgently come review Janet.
You immediately call your registrar and update them. With a sigh, they agreed to come join you to review Janet.
You hang up, and prepare to head back to the bedside. Perhaps antipsychotics aren't the solution to all problems?
---
[[Continue->gameover]]
---(set: $DDx1 to "anxiety")
You decide that Janet's main problem is anxiety. She's finding it painful to mobilise after surgery, and she's worried that she won't walk again. That's why her heart rate and respiratory rate have been high.
The cough? That doesn't quite fit, but everyone gets a cough once in a while, and the hospital is full of viruses.
You give a comforting squeeze on Janet's shoulder and let her know that everything will be allright. She smiles and thanks you for your time.
An hour later, when walking back from the cafe after your 3rd coffee, you hear the PA system announce the news that you don't want:
(b4r:"solid","none")+(b4r-colour:purple)+(text-style:"bold")+(text-colour:red)[MEDICAL EMERGENCY TEAM. WARD 3. GENERAL SURGICAL UNIT. MEDICAL EMERGENCY TEAM. WARD 3. GENERAL SURGICAL UNIT.]
You down the coffee, take a breath, and get ready for some difficult conversations ahead.
---
[[Continue->gameover]]
---(set: $DDx1 to "acute decompensated heart failure")
You decide that Janet has an acute decompensation of her underlying heart failure with preserved ejection fraction (HFpEF).
You clarify that Janet does not have any acute chest pain and is haemodynamically stable.
What would you like to do next?
---
[[Order investigations->1-Ix]]
---(set: $DDx1 to "noproblems")
You decide that Janet is fine. She's had her surgery and all other problems will sort themselves out. You give a comforting squeeze on Janet's shoulder and let her know that everything will be alright. She smiles and thanks you for your time.
An hour later, when walking back from the cafe after your 3rd coffee, you hear the PA system announce the news that you don't want:
(b4r:"solid","none")+(b4r-colour:purple)+(text-style:"bold")+(text-colour:red)[MEDICAL EMERGENCY TEAM. WARD 3. GENERAL SURGICAL UNIT. MEDICAL EMERGENCY TEAM. WARD 3. GENERAL SURGICAL UNIT.]
You down the coffee, take a breath, and get ready for some difficult conversations ahead.
---
[[Continue->gameover]]
---(set: $DDx1 to "hospital-acquired pneumonia")
You are concerned that Janet could have hospital-acquired pneumonia, given her new onset of a productive cough with yellow-green sputum, along with tachycardia/tachypnoea and new supplemental oxygen requirement.
You decide to order some investigations to support or refute your provisional diagnosis.
---
[[Order some investigations->1-Ix]]
---''Thanks for playing''
<img src="media/title_medium.png">
Evidence-based medicine is difficult to integrate into routine clinical practice, especially for junior staff. We hope this module has given you some practical ideas to take forward in your clinical careers.
We look forward to meeting you for the interactive session on (text-colour:red)+(text-style:"bold")[11th April 2024].
Learn more about EBMQuest [[here->About]].
Any questions or feedback can be directed to:
<a href="mailto:aiden.varan@gmail.com?subject=EBMQuest Feedback: &">aiden.varan@gmail.com</a>
Thanks :)
Aiden, on behalf of the EBMQuest Team
---
[[Title Page->TitleScreen]]
---
<img src=media/insideED.jpeg>
There are several patients currently waiting to be seen.
Your consultant advised you to initially focus on <a href="https://acem.org.au/Content-Sources/Advancing-Emergency-Medicine/Better-Outcomes-for-Patients/Triage" target="_blank" rel="noopener"> ATS Cat 3-4 </a> patients.
You see that Robert, a 21-year-old male presenting with a "fainting episode", is waiting in Bay 7.
After clicking 'assign me', you see ''Dr. $playerfirstname $playerlastname'' next to Robert's name. You proceed to open his record.
---
[[Review Robert's file->2-caseoverview]]
---What investigations would you like to order now for Janet to support or refute your provisional diagnosis of ''$DDx1''?
Bedside:
(checkbox: 2bind $1_Ix_ECG,"ECG")
(checkbox: 2bind $1_Ix_glucose,"POCT glucose")
(checkbox: 2bind $1_Ix_dipstick,"Urine dipstick")
(checkbox: 2bind $1_Ix_urineMCS,"urine MCS")
(checkbox: 2bind $1_Ix_sputum,"Sputum MCS")
Serology:
(checkbox: 2bind $1_Ix_FBE,"FBE")
(checkbox: 2bind $1_Ix_UEC,"UEC")
(checkbox: 2bind $1_Ix_LFT,"LFT")
(checkbox: 2bind $1_Ix_CRP,"CRP")
(checkbox: 2bind $1_Ix_ESR,"ESR")
(checkbox: 2bind $1_Ix_BNP,"nt-pro-BNP")
(checkbox: 2bind $1_Ix_SPE,"serum protein electrophoresis")
Imaging:
(checkbox: 2bind $1_Ix_CXR,"CXR")
(checkbox: 2bind $1_Ix_CTchest,"CT Chest")
(checkbox: 2bind $1_Ix_echo,"Echocardiography")
(checkbox: 2bind $1_Ix_cardiacMRI,"Cardiac MRI")
---
[[Continue->1-Ixresults]]
---You place these orders and start work on other jobs. A few hours later, you re-check the results available to date:
''Bedside:''
(if:$1_Ix_ECG is true)[ECG: Sinus tachycardia with right axis deviation. Nil ST segment changes. ](if:$1_Ix_glucose is true)[Glucose: 5.8. ]
(if:$1_Ix_dipstick is true)[Urine dipstick: Nil leukocytes or nitrites. Protein +. Nil red blood cells. ](if:$1_Ix_urineMCS is true)[Urine MCS: Mixed growth detected with ++ squamous epithelial cells. + leukocytes. Nil nitrites. Nil blood. ](if:$1_Ix_sputum is true)[Sputum MCS: Gram positive cocci detected. Formal results inc. sensitivities pending. ]
''Serology:''
(if:$1_Ix_FBE is true)[FBE:"Hb 120. Elevated WCC (13.5; ref 4.0-12.0) with neutrophilia (9.0; ref 2.0-8.0). ](if:$1_Ix_UEC is true)[UEC: All parameters within normal limits. ](if:$1_Ix_LFT is true)[LFT: All parameters within normal limits. ](if:$1_Ix_CRP is true)[CRP=55 (ref <5). ]
(if:$1_Ix_ESR is true)[ESR=10 (ref 7-18). ](if:$1_Ix_BNP is true)[nt-pro-BNP: Results pending (will take some time to come back). ](if:$1_Ix_SPE is true)[Serum protein electrophoresis: Results pending (will take some time to come back).]
//''Did all of these investigations help you? Were they all necessary?''//
[[Continue->Ixresults2]]
---You place the order for a CTPA and then phone the duty radiologist to request for protocol for the scan. You discuss the clinical history and your concern for a PE, and notify that you've calculated the Wells score is $wellsscore.
They report that, based on the clinical history and examination findings to date, they assess Janet as having a Wells score of (text-style:"bold")+(text-colour:red)[3]. While her recent post-operative history increases her risk, her overall likelihood is still low.
<img src="media/janetwellsscore.png">
They advise that you could consider a D-dimer test in line with PE evalution algorithms. However, noting that she has new onset productive cough without haemoptysis, as well as tachycardia and tachypnoea, they suggest that pneumonia would be an important differential to consider, and would be at least as likely as PE in this case.
Hence, they advise you to first order a chest X-ray. If there is ongoing concern for PE, and especially if Janet develops clinical symptoms consistent with a DVT, they recommend to re-discuss with radiology.
You thank them and hang up, and then sigh in relief. That was a hard call, but you now have some guidance.
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: Clinical prediction rules for pulmonary embolism ->EBM-PE]]]
---
[[Order some investigations->1-Ix]]
---''EBM Teaching Point: Clinical prediction rules for pulmonary embolism''
Source: Chunilal SD, Eikelboom JW, Attia J, et al. Does This Patient Have Pulmonary Embolism? JAMA. 2003;290(21):2849–2858. <a href="https://jamanetwork.com/journals/jama/article-abstract/197765" target="_blank" rel="noopener">doi:10.1001/jama.290.21.2849</a>
Objective: To evaluate and demonstrate the accuracy of pretest probability assessment for pulmonary embolism using clinical gestalt vs clinical prediction rules
Conclusion: The clinical gestalt of experienced clinicians and the clinical prediction rules used by physicians of varying experience have shown similar accuracy in discriminating among patients who have a low, moderate, or high pretest probability of pulmonary embolism. We advocate the use of a clinical prediction rule because it has shown to be accurate and can be used by less-experienced clinicians.
---
(link-undo:"Go Back")
---(b4r:"inset","none")+(b4r-colour:orange,orange)[EBM Teaching Point: ]
Reference: Wong CL, Holroyd-Leduc J, Straus SE. Does This Patient Have a Pleural Effusion? JAMA. 2009;301(3):309–317. <a href="https://jamanetwork.com/journals/jama/article-abstract/183247" target="_blank">doi:10.1001/jama.2008.937</a>
The best performing manoeuvre to diagnose pleural effusion was the presence of dullness to percussion (LR+=8.7; 95% CI: 2.2-33.8). Where tactile vocal fremitus was not reduced, pleural effusion was less likely (LR-=0.21; 95% CI:0.12-0.37)
---
(link-undo:"Go Back")
---How would you like to manage Janet's condition, based on your principal diagnosis of ''$DDx1''?
---
[[Chart IV fluids->1-Rx-fluids]]
[[Chart antibiotics->1-Rx-ABx]]
[[Chart diuretics->1-Rx-diuretics]]
---You scroll down to look for imaging results:
''Imaging: ''
(if:$1_Ix_CXR is true)[CONCLUSION: Chest hyperexpansion and flattening of diaphragm bilaterally in keeping with clinical history of COPD. Dense consolidation noted in right middle lobe consistent with lobar pneumonia. Blunting of costophrenic angles bilaterally suggestive of pleural effusion. Nil pneumothorax or haemothorax. Nil rib fractures identified.]
(if:$1_Ix_CTchest is true)[CT study not yet scheduled. You will need to discuss with the duty radiologist to have protocoled.]
(if:$1_Ix_echo is true)[Echocardiography not yet scheduled. You will need to discuss with the echocardiology fellow to have protocoled.]
(if:$1_Ix_cardiacMRI is true)[MRI study not yet scheduled. You will need to discuss with the duty radiologist to have protocoled.]
---
What would you like to do next?
(if:$1_Ix_CTchest is false)[[[Call the radiologist to protocol a CT->1-CTprotocol]]]
(if:$1_Ix_echo is false)[[[Call the echocardiology fellow to protocol the echo->1-echoprotocol]]]
(if:$1_Ix_cardiacMRI is false)[[[Call the radiologist to protocol a cardiac MRI->1-MRIprotocol]]]
[[Alter your principal diagnosis->1-ddx]]
[[Chart some medications->1-Rx]]
---You call the duty radiologist to request for a CT chest.
(if:$1_Ix_CXR is true)[They note that a CXR has already been performed which identifies a lobar pneumonia. Hence, unless there is another clinical concern, they do not advise a CT chest at this time]
(if:$1_Ix_CXR is false)[They note that a CXR has not yet been performed, and should be assessed in the first instance as a cheaper, quicker investigation with less associated radiation exposure]
What would you like to do next?
---
[[Order some investigations->1-Ix]]
[[Chart some medications->1-Rx]]
---You try to call the echo fellow but the line is busy. You leave a voicemail and request callback. This will probably take a while...
What would you like to do now?
---
[[Order some investigations->1-Ix]]
[[Chart some medications->1-Rx]]
---Enter your IV fluid prescription:
''Type''
(dropdown: 2bind $fluidtype1,"N Saline (0.9% NaCl)","CSL / Hartmanns Solution","Plasmalyte")
''Volume''
1L (fixed)
''Rate''
(dropdown: 2bind $fluidrate1,"Stat","1/24 (999ml/hr)","2/24 (500ml/hr)","4/24 (250ml/hr)","8/24 (125ml/hr)","10/24 (100ml/hr)","12/24 (83ml/hr)")
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: physical examination for hypovolaemia ->EBM-hypovolaemia]]]
---
[[Continue->1-Rx-fluids2]]
---You opt to order some antibiotics for Janet, on the basis of presumed ''$DDx1''.
(if:$DDx1 is "hospital-acquired pneumonia")[What antibiotic regimen do you want to prescribe?
(input-box:2bind $RxABx1,"X",1)
---
[[Continue->1-Rx-ABx2]]]
(else:)[Why do you want to order antibiotics for $DDx1? Maybe it's time to reconsider your diagnosis...
[[Revise your diagnosis->1-ddx]]]
---You commence Janet on the following regimen:
//Furosemide 40mg IV BD//
with a first dose to be given now.
Returning around an hour later, you note that her peripheral pitting oedema has lessened, and she is mildly less short of breath. However, she is still tachycardic at 105bpm, has now spiked a fever at 38.2 C, and has ongoing productive cough. You feel weary to continue prescribing diuretics given a suboptimal response to date.
What would you like to do now?
---
[[Reconsider your provisional diagnosis->1-ddx]]
[[Order some investigations->1-Ix]]
--- You write up an order for 1L ''$fluidtype1'' running at ''$fluidrate1''.
When you are just about to finalise the order, your registrar calls and requests an update. You explain that you are treating Janet for a provisional diagnosis of ''$DDx1'' and want to give her IV fluids as part of her management.
Your registrar asks whether Janet is eating and drinking. You remember back to her half-eaten breakfast, but acknowledge that she has generally been having good oral intake on the wards.
She asks whether you think IV fluids are necessary and valuable in this context. Specifically, she asks whether you think that Janet is 'running dry' (hypovolaemic).
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: physical examination for hypovolaemia ->EBM-hypovolaemia]]]
You think back and, although did not formally assess her fluid status, do not believe that she is hypovolaemic. Indeed, you recall her peripheral pitting oedema suggestive of potential fluid overload.
You agree that, in this context, IV fluids would not be helpful and might be harmful. She advises you to reconsider your management plan before scrubbing in for the next case.
What would you like to do next?
---
[[Reconsider your provisional diagnosis->1-ddx]]
[[Order some investigations->1-Ix]]
[[Chart some medications->1-Rx]]
---''EBM Teaching Point: physical examination for hypovolaemia''
Source: McGee S, Abernethy III WB, Simel DL. Is This Patient Hypovolemic? JAMA. 1999;281(11):1022–1029. <a href="https://jamanetwork.com/journals/jama/article-abstract/189113" target="_blank" rel="noopener">doi:10.1001/jama.281.11.1022</a>
Results: In patients with vomiting, diarrhea, or decreased oral intake, the presence of a dry axilla supports the diagnosis of hypovolemia (positive likelihood ratio, 2.8; 95% CI, 1.4-5.4), and moist mucous membranes and a tongue without furrows argue against it (negative likelihood ratio, 0.3; 95% CI, 0.1-0.6 for both findings). In adults, the capillary refill time and poor skin turgor have no proven diagnostic value.
---
(link-undo:"Go Back")
---You try to call the duty radiologist to protocol the cardiac MRI. They are inquisitive, asking why you think it is indicated.
You struggle for words, frantically scrolling Google for an eloquent justification.
"I want to know more about the heart," you proclaim.
Alas, the duty radiologist is not biting. They launch into a minor tirade about evidence-based medicine and avoiding unnecessary scans for which there is no relevant indication.
You thank them, take a deep breath, and let out a long sigh. It's going to be a long shift. Time to brush up on some evidence-based medicine.
---
[[Continue->gameover]]
---(if:visits is 4)[The pharmacist advises you that you have made too many revisions to the order and the nursing staff are getting confused. She has notified your registrar who has stepped in on your behalf.
[[Continue->gameover]]](else:)[You chart Janet ''$RxABx1''.
A few minutes later, you get a call from the ward pharmacist. She informs you that the order placed was 'free-text' and they require a system-coded order for dispensing. Ideally, you would choose an evidence-based treatment regimen.
What would you like to chart?
Drug and dosage:
(dropdown: 2bind $rx1_drugname,
"amoxicillin+clavulanate 1g+200mg",
"amoxicillin+clavulanate 875mg+125mg",
"cefepime 2g",
"cefotaxime 1g",
"ceftriaxone 1g",
"cefuroxime 500mg",
"meropenem 1g",
"moxifloxacin 400mg",
"piperacillin+tazobactam 4g+500mg",
)
Route:
(dropdown: 2bind $rx1_route,
"Oral",
"NG",
"NJ",
"IM",
"IV",
)
Frequency:
(dropdown: 2bind $rx1_freq,
"Continuous",
"4 hourly",
"6 hourly (QID)",
"8 hourly (TDS)",
"12 hourly (BD)",
"24 hourly (daily)",
)
---
[[Continue->1-Rx-Abx3]]]
---
=|=
=|=
(text-style:"bold","wavy-underline","emboss","expand","buoy")+(b4r:"solid")+(b4r-size:3)+(b4r-colour:red)[GAME OVER]
=|=
|==|
---
[[Return->ChooseScenario]]
---(unless: (passage:)'s tags contains "no-header")[
=|=
[[<img src="media/restart.png">->ChooseScenario]]
=|=
=|=
=|=
=|=
=|=
[[<img src="media/researchhub.png">->researchhub]]
|==|
---
]<img src="media/scenario2_full.jpg">
The triage notes read as follows:
//''Robert Zildan''. 21yoM retail assistant presenting with syncope. C/o sore head and R arm. PHx R #clavicle, tonsillectomy. Smoker 1/2 pack daily. //
Looking back on his record, Robert has presented once to this ED following a bicycle accident where he sustained a fracture of his clavicle that was conservatively managed. There is a brief history of the accident but no other information.
---
[[Go see Robert->2-firstmeet]]
---You enter Robert's cubicle, sanitise your hands, and take a seat next to his bedside.
Robert is lying back quietly on the bed. Continuous monitoring is active and shows vital signs within normal limits except for a mild tachycardia (HR 105bpm). His most recent blood pressure recording is 135/75.
On arrival in ED, Robert had a POCT blood glucose (5.7) and ECG performed (sinus tachycardia, otherwise NAD). No other investigations have been performed so far.
What would you like to do now?
---
[[Take a history->2-ED-hx]]
[[Perform a physical exam->2-ED-oe]]
[[Order investigations->2-ED-horses]]
[[Prescribe medications->2-ED-horses]]
---(if:$rx1_drugname is "amoxicillin+clavulanate 875mg+125mg" and $rx1_route is "Oral" and $rx1_freq is "12 hourly (BD)")
[Your pharmacist calls you back to congratulate you! You have studiously reviewed the current edition of Therapeutic Guidelines and are prescribing in line with best-practice guidance.
---
[[Continue->1-postRx]]]
(else:)
[The pharmacist calls you back and has further questions about your prescribing choice. She politely suggests to double-check the Therapeutic Guidelines for recommendations on first line management of hospital-acquired pneumonia.
---
[[Alter your prescription->1-Rx-ABx2]]
[[Thank the pharmacist but continue with your order as written->1-stubborn]]]
---Over the next few days, Janet shows a steady improvement from her pneumonia on appropriate antimicrobial therapy. Her respiratory rate settles to within normal limits, and her oxygen saturation improves.
You brief your registrar on Janet's progress after she returns from theatre later that afternoon. She is impressed by your diligence and agrees with your plan. //''"Nice work today, $playerfirstname,"''// she calls out walking away. You can't help but smile as you finish your jobs for the day.
---
[[Continue->1-nextfewdays]]
---You thank the pharmacist for her concern but assure her that ''$rx1_drugname $rx1_route $rx1_freq'' is the right treatment for this patient. You are, after all, the doctor.
Feeling the power of your pen (figuratively, since you are electronically prescribing), you ease back in your chair.
But did you come off too strong?
---
[[Call back the pharmacist to repent-->1-callbackpharm]]
[[Leave the order as is->1-IDcall]]
---Ten minutes later, you receive a call from the Infectious Diseases consultant on call. They do not sound pleased.
They question your choice of prescription and your reluctance to listen to the pharmacist's advice. You start to justify your decision, but are swifly interrupted by the consultant.
//This is medicine, ''$playerfirstname''. We need to trust the evidence. //
---
[[Continue->gameover]]
---You call back the pharmacist and apologise. Sometimes the power of the job can get to your head...
The pharmacist accepts your apology and requests you to revise your order for Janet.
---
[[Revise your order->1-Rx-ABx2]]
---Today, you've been rostered onto a long shift including evening cover.
You see Janet briefly on your morning round. She seems a little more confused than before. But no-one is at their best for early morning surgical rounds, right? You quickly run to catch up with the round, and find yourself busy with other jobs during the day.
---
[[Continue->1-calledbynurses]]
---That evening, it's been a busy cover shift managing patients from several teams. You arrive in ressies for a quick break and cup of tea in your favourite $playerfavcolour mug.
Just as you are about to enjoy that first sip, you get the following page:
(b4r:"solid","none")+(b4r-colour:white)[(text-colour:green)+(background:black)[KILMORE 9374812 WARD 3 BED 12 CONFUSED ++ AND SHOUTING. PLEASE COME ASAP. MEG X97418.]]
This will take some time. You mournfully pour out your tea and begin walking upstairs.
---
[[Go to Janet's bedside->1-pt2-atbedside]]
---When you arrive on the ward, you can hear Janet from the end of the corridor. She is screaming and crying loudly.
A nearby nurse informs you that Janet has been 'increasingly confused' today. //"All the other patients are having trouble sleeping because of her outbursts,"// the exasperated nurse proclaims. //"Could you prescribe something to settle her for the night?"//
What do you do next?
---
[[Go review Janet->1-pt2-review]]
[[Prescribe some sedating medications->1-pt2-sedatives]]
---Janet is highly distressed as you approach her bedside. She is crying and continuously asking, //"Why am I here? Take me home! Oh God, oh God!"//.
You try to introduce yourself to Janet as one of her doctors, but Janet doesn't recognise you and becomes more worried. She yells out for ''Michelle'', her daughter.
What do you do next?
---
[[Review her medical record->1-pt2-medrecord]]
[[Take a history from Janet->1-pt2-hx]]
[[Perform a physical examination->1-pt2-oe]]
[[Order some investigations->1-pt2-ix]]
[[Call Janet's medical treatment decision maker->1-pt2-MTDM]]
[[Prescribe some sedatives->1-pt2-sedatives]]
[[Request nursing staff to restrain Janet->1-pt2-restrain]]
[[Leave the nurses to sort this one out->1-pt2-leavenurses]]
---You decide to prescribe sedatives to help with managing Janet's delirium.
What would you like to prescribe?
(input-box:2bind $Rxsedativefreetext,"X",1)
(b4r:"solid","none")+(b4r-colour:orange,white)[[EBM Practice Point: Sedatives for delirium->EBM-sedatives]]
---
[[Continue->1-pt2-sedatives2]]
(link-undo:"On second thought...")
---You decide to order some basic investigations for Janet.
What would you like to order?
Bedside:
(checkbox: 2bind $1_Ix2_ECG,"ECG")
(checkbox: 2bind $1_Ix2_glucose,"POCT glucose")
(checkbox: 2bind $1_Ix2_dipstick,"Urine dipstick")
(checkbox: 2bind $1_Ix2_urineMCS,"Urine MCS")
(checkbox: 2bind $1_Ix2_sputum,"Sputum MCS")
---
[[Continue->1-pt2-results]]
---Results come back for Janet's initial investigations as follows:
''Bedside:''
(if:$1_Ix2_ECG is true)[ECG: Poor quality study due to movement artefact. Sinus tachycardia with right axis deviation. Nil ST segment changes. ] (if:$1_Ix2_glucose is true)[Glucose: 6.1 ] (if:$1_Ix2_dipstick is true)[Urine dipstick: + leuk + nitrites. Nil rbc. ] (if:$1_Ix2_urineMCS is true)[Urine MCS: Pending ] (if:$1_Ix2_sputum is true)[Sputum MCS: Unable to collect as patient uncooperative ]
What would you like to do next?
---
(unless:$deliriumnpidone is true)[[[Speak with the nursing staff about management strategies->1-pt2-npi]]]
(unless:$utiabxdone is true)[[[Chart antibiotics->1-pt2-abx]]]
[[Prescribe some sedatives->1-pt2-sedatives]]
[[Request nursing staff to restrain Janet->1-pt2-restrain]]
[[Leave the nurses to sort this one out->1-pt2-leavenurses]]
---(if:visits >= 1)[(set: $complete1a to true)]
Congratulations! You have finished Scenario 1a!
<img src=media/winner.jpg>
EBM pearls from this scenario:
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: Physical Examination for Pleural Effusion->EBM-respexam]]]
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: Clinical prediction rules for pulmonary embolism ->EBM-PE]]]
(b4r:"solid","none")+(b4r-colour:orange,white)[[[EBM Practice Point: physical examination for hypovolaemia ->EBM-hypovolaemia]]]
---
[[Choose another scenario->ChooseScenario]]
---You gently step back and head down the stairs. The nurses should be able to handle this one, right?
About twenty minutes later, you hear the following announcement over the loudspeaker,
(b4r:"solid","none")+(b4r-colour:purple)+(text-style:"bold")+(text-colour:red)[MEDICAL EMERGENCY TEAM. WARD 3. GENERAL SURGICAL UNIT. MEDICAL EMERGENCY TEAM. WARD 3. GENERAL SURGICAL UNIT.]
You sigh and prepare to head back upstairs.
---
[[Continue->gameover]]
---You try engaging with Janet but she is too distressed and just keeps yelling out for Michelle.
---
[[Perform a physical examination->1-pt2-oe]]
[[Order some investigations->1-pt2-ix]]
[[Call Janet's medical treatment decision maker->1-pt2-MTDM]]
[[Prescribe some sedatives->1-pt2-sedatives]]
[[Request nursing staff to restrain Janet->1-pt2-restrain]]
[[Leave the nurses to sort this one out->1-pt2-leavenurses]]
---You attempt to examine Janet but she is too distressed to remain still. She cries out for Michelle as you try to lie her back in the bed. However, you notice that she has urinated in her bed, which is unusual for her. Although Janet suffers with Alzheimer's dementia, she does not normally experience urinary incontinence.
---
[[Order some investigations->1-pt2-ix]]
[[Call Janet's medical treatment decision maker->1-pt2-MTDM]]
[[Prescribe some sedatives->1-pt2-sedatives]]
[[Request nursing staff to restrain Janet->1-pt2-restrain]]
[[Leave the nurses to sort this one out->1-pt2-leavenurses]]
---You check Janet's medical record to identify her medical treatment decision maker (MTDM). It lists her son Jacob as the primary point of contact, and the nursing home as a secondary contact.
You try Jacob's number but cannot reach him. You quietly curse the use of private numbers for outgoing calls from the hospital, and sigh.
---
[[Review the rest of the medical record->1-pt2-medrecord]]
[[Take a history from Janet->1-pt2-hx]]
[[Perform a physical examination->1-pt2-oe]]
[[Order some investigations->1-pt2-ix]]
[[Prescribe some sedatives->1-pt2-sedatives]]
[[Request nursing staff to restrain Janet->1-pt2-restrain]]
[[Leave the nurses to sort this one out->1-pt2-leavenurses]]
---You find Janet's medical record (now conveniently located in its appropriate spot!) and read back on today's notes.
You find your brief ward round note this morning and read onwards.
The daytime nurse had noted that Janet was somewhat confused today, but they hadn't looked after Janet before so was unsure of her baseline. Her vital signs were consistent with prior recordings.
Janet was sleeping most of the afternoon. She was rousable when awoken but the allied health teams hadn't been able to get her out of bed for post-operative rehabilitation.
Since about 6pm, nursing staff noted that Janet had become more irritable. They had tried to redirect her with limited success. Nursing staff attempted to reach the medical resident but the line was constantly busy.
Janet was being frequently monitored with concern for escalating agitation. By around 8pm, her behaviours had worsened and the nursing staff escalated for urgent medical staff review.
---
[[Take a history from Janet->1-pt2-hx]]
[[Perform a physical examination->1-pt2-oe]]
[[Order some investigations->1-pt2-ix]]
[[Call Janet's medical treatment decision maker->1-pt2-MTDM]]
[[Prescribe some sedatives->1-pt2-sedatives]]
[[Request nursing staff to restrain Janet->1-pt2-restrain]]
[[Leave the nurses to sort this one out->1-pt2-leavenurses]]
---You speak with the ANUM about implementing appropriate management strategies for Janet's delirium.
What would you like to recommend?
(input-box:2bind $npirec,"=XX=")
(b4r:"solid","none")+(b4r-colour:orange,white)[[EBM Practice Point: non-pharmacological management of delirium->EBM-npi]]
---
[[Continue->1-pt2-npi2]]
---(if:(history: where it is "1-pt2-oe")'s length >= 1)[You are concerned about her new onset urinary incontinence.] (if:$1_Ix2_dipstick is true)[You note the positive leukocytes and nitrites on her urine dipstick.] You decide to start Janet on empiric antibiotic therapy.
What would you like to prescribe?
Drug:
(dropdown: 2bind $rx1_uti_drugname,
"amoxicillin",
"cefalexin",
"ciprofloxacin",
"fosfomycin",
"nitrofurantoin",
"norfloxacin",
"trimethoprim",
)
Dosage:
(dropdown: 2bind $rx1_uti_dose,
"100mg",
"200mg",
"300mg",
"400mg",
"500mg",
"1g",
"2g",
"3g",
)
Route:
(dropdown: 2bind $rx1_uti_route,
"Oral",
"NG",
"IM",
"IV",
)
Frequency:
(dropdown: 2bind $rx1_uti_freq,
"Once only",
"4 hourly",
"6 hourly (QID)",
"8 hourly (TDS)",
"12 hourly (BD)",
"24 hourly (daily)",
)
---
[[Continue->1-pt2-abx2]]
---Based on your recommendations, the bedside nursing prepare physical restraints for Janet.
Unexpectedly, your registrar approaches and sees the straps being readied. She looks wearily at you.
//"Restrain Janet? But she's just a little old lady who is scared and confused. She hasn't hurt anybody. Can't we go for a more gentle approach, $playerfirstname?"//
You regret having jumped to such an extreme measure, and thank your registrar for the teaching.
(b4r:"solid","none")+(b4r-colour:orange,white)[[EBM Practice Point: Physical restraints in delirium/BPSD->EBM-restraint]]
---
[[Continue->gameover]]
---As per <a href="https://www.choosingwisely.org.au/recommendations/anzsgm5" target="_blank" rel="noopener"> Choosing Wisely recommendations </a> from the Australian and New Zealand Society for Geriatric Medicine:
(b4r:"solid")+(b4r-size:2)+(b4r-colour:(hsl:240,0.8039,0.5,0.5),(hsl:240,0.8039,0.5,0.5),(hsl:240,0.8039,0.5,0.55),(hsl:240,0.8039,0.5,0.55))[5. Do not use physical restraints to manage behavioural symptoms of hospitalized older adults with delirium except as a last resort.]
---
(link-undo:"Go back")
---After attempting to place your order for ''$Rxsedativefreetext'', the after-hours pharmacist informs you that the order placed was 'free-text'. They require a system-coded order for dispensing. Ideally, you would choose an evidence-based treatment regimen.
What would you like to chart?
Drug"
(dropdown: 2bind $rx1_sedative_drugname,
"diazepam",
"haloperidol",
"olanzapine",
"quetiapine",
"risperidone",
"temazepam",
)
Dosage:
(dropdown: 2bind $rx1_sedative_dose,
"0.25mg",
"0.5mg",
"0.75mg",
"1mg",
"1.25mg",
"1.5mg",
"2mg",
"5mg",
"10mg",
"20mg",
"25mg",
"50mg",
)
Route:
(dropdown: 2bind $rx1_sedative_route,
"Oral",
"NG",
"IM",
"IV",
)
Frequency:
(dropdown: 2bind $rx1_sedative_freq,
"Once only",
"4 hourly",
"6 hourly (QID)",
"8 hourly (TDS)",
"12 hourly (BD)",
"24 hourly (daily)",
)
PRN?
(dropdown: 2bind $rx1_sedative_PRN,
"PRN",
"regular",
)
(b4r:"solid","none")+(b4r-colour:orange,white)[[EBM Practice Point: Sedatives for delirium->EBM-sedatives]]
---
[[Continue->1-pt2-sedatives3]]
---You prescribe $rx1_sedative_drugname $rx1_sedative_dose $rx1_sedative_route $rx1_sedative_freq $rx1_sedative_PRN.
After administration, Janet is initially more settled and sleepy. You attend to other ward jobs.
However, just as you are heading to handover to the night team, you hear over the loudspeaker,
(b4r:"solid","none")+(b4r-colour:purple)+(text-style:"bold")+(text-colour:red)[MEDICAL EMERGENCY TEAM. WARD 3. GENERAL SURGICAL UNIT. MEDICAL EMERGENCY TEAM. WARD 3. GENERAL SURGICAL UNIT.]
You sigh. Perhaps the sedatives weren't such a good idea after all...
(b4r:"solid","none")+(b4r-colour:orange,white)[[EBM Practice Point: Sedatives for delirium->EBM-sedatives]]
---
[[Continue->gameover]]
---As per <a href="https://www.choosingwisely.org.au/recommendations/anzsgm1" target="_blank" rel="noopener"> Choosing Wisely recommendations </a> from the Australian and New Zealand Society for Geriatric Medicine:
(b4r:"solid")+(b4r-size:2)+(b4r-colour:(hsl:240,0.8039,0.5,0.5),(hsl:240,0.8039,0.5,0.5),(hsl:240,0.8039,0.5,0.55),(hsl:240,0.8039,0.5,0.55))[1. Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.]
''Per a 2016 Cochrane review by Siddiqi et al. entitled, <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005563.pub3/full" target="_blank" rel="noopener">"Interventions for preventing delirium in hospitalised non‐ICU patients"</a>,''
//"There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium."//
---
(link-undo:"Go back")
---Over the next few days, Janet has shown steady clinical improvement. Her tachypnoea has settled, and her supplemental oxygen requirements have ceased. She has been engaging well with post-operative rehabilitation.
Your registrar has been asking for daily CRP tests to monitor the resolution of her infection.
However, recalling a <a href="https://www.choosingwisely.org.au/recommendations/imsanz2" target="_blank" rel="noopener"> helpful practice point from the Choosing Wisely campaign </a>, you have remained steadfast that this is not required as she is clinically improving, is not immunocompromised, and her infection has not been severe.
With some pushback, you have been effective at rationalising her investigations, saving her unnecessary blood tests and avoiding system costs that won't change management. Hooray!
---
[[Continue->1a-winner]]
---Having finished explaining your plan in an eloquent monologue, and taking a breath in, the "ANUM" finally responds and inform you that they are, in fact, the ''ward clerk''.
They've been trying to tell you but you were so excited to think about delirium management that they couldn't get a word in!
Alas, you thank the ward clerk for their patience and walk over to speak with Michelle, the ANUM on shift this evening.
Which of the following strategies would you recommend for Janet's management?
(checkbox: 2bind $npi1_mtdm,"Try to reach Janet's medical treatment decision maker")
(checkbox: 2bind $npi1_obs,"Move Janet to a quiet area where she can be constantly observed")
(checkbox: 2bind $npi1_sneak,"Advise staff to sneak around her bedside to avoid being hit")
(checkbox: 2bind $npi1_staff,"Try to use fewer, consistent staff to care for Janet")
(checkbox: 2bind $npi1_cam,"Ask staff to perform regular CAM scores")
(checkbox: 2bind $npi1_orient,"Provide frequent orientation (time, place, person")
(checkbox: 2bind $npi1_cannularemove,"Remove her IV cannula")
(checkbox: 2bind $npi1_restraint,"Advise a low threshold for physical restraint")
(checkbox: 2bind $npi1_sedation,"Place an order for sedation medication to be used as needed")
(b4r:"solid","none")+(b4r-colour:orange,white)[[EBM Practice Point: non-pharmacological management of delirium->EBM-npi]]
---
[[Continue->1-pt2-npi3]]
---(if:visits is 4)[The pharmacist advises you that you have made too many revisions to the order and the nursing staff are getting confused. She has notified your registrar who has stepped in on your behalf.
[[Continue->gameover]]] (else-if:$rx1_uti_drugname is "trimethoprim" and $rx1_uti_dose is "300mg" and $rx1_uti_route is "Oral" and $rx1_uti_freq is "24 hourly (daily)")[Congratulations! You have studiously reviewed the current edition of Therapeutic Guidelines and are prescribing in line with best-practice guidance.(set: $utiabxdone to true)
---
[[Continue->1-pt2-prefinal]]](else-if:$rx1_uti_drugname is "nitrofurantoin" and $rx1_uti_dose is "100mg" and $rx1_uti_route is "Oral" and $rx1_uti_freq is "6 hourly (QID)")[Congratulations! You have studiously reviewed the current edition of Therapeutic Guidelines and are prescribing in line with best-practice guidance.(set: $utiabxdone to true)
---
[[Continue->1-pt2-prefinal]]](else-if:$rx1_uti_drugname is "cefalexin" and $rx1_uti_dose is "500mg" and $rx1_uti_route is "Oral" and $rx1_uti_freq is "12 hourly (BD)")[Congratulations! You have studiously reviewed the current edition of Therapeutic Guidelines and are prescribing in line with best-practice guidance.(set: $utiabxdone to true)
---
[[Continue->1-pt2-prefinal]]](else:)[The on-call pharmacist calls you back and has further questions about your prescribing choice. She politely suggests to double-check the Therapeutic Guidelines for recommendations on first line management
---
[[Alter your prescription->1-pt2-abx]]
[[Thank the pharmacist but continue with your order as written->1-stubborn2]]]
---It's too late for the pharmacist to fight with you, so they back down and allow you to complete your order as charted.
However, the next day, your consultant brings a printout with the following order:
(b4r:"solid")+(b4r-size:2)+(b4r-colour:(hsl:0,0,1,0.55),(hsl:0,0,1,0.5),(hsl:0,0,1,0.55),(hsl:0,0,1,0.55))[
$rx1_uti_drugname $rx1_uti_dose $rx1_uti_route $rx1_uti_freq]
''Is this your work, Dr. $playerlastname? Didn't the pharmacist try to encourage you to use evidence-based practice?''
Sheepishly, you say yes. No coffee this time. It will be a long day ahead.
---
[[Continue->gameover]]
---(b4r:"solid","none")+(b4r-colour:orange,white)[[EBM Practice Point: non-pharmacological management of delirium->EBM-npi]]
(if:$npi1_mtdm is false and $npi1_obs is false and $npi1_cam is false and $npi1_staff is false and $npi1_orient is false and $npi1_idcremove is false)[The ANUM is weary of your plan and escalates to her senior nursing colleagues. Your registar is notified, who is concerned with your management planning of Janet's delirium and advises you to review evidence-based practice for delirium.
---[[Continue->gameover]]](else-if:$npi1_restraint is true)[You finish providing your recommendations to the ANUM including low threshold for restraint.
---[[Continue->1-pt2-restrain]]](else-if:$npi1_sedation is true)[You finish providing your recommendations to the ANUM including plans for PRN orders for sedatives.
---[[Continue->1-pt2-sedatives]]](else:)[(if:$npi1_mtdm is true)[Nursing staff try to reach Jacob, Janet's son. He appreciates the call and is put on loudspeaker to talk with Janet. The interaction with a familar voice seems to settle her somewhat. ](if:$npi1_obs is true)[Janet is moved to a quiet room with low lighting where she can be readily observed. ](if:$npi1_sneak is true)[Staff initially try 'sneaking' around Janet's bedside to avoid being hit. However, she is startled by staff coming from her side, triggering more agitation. Hence, they return to standard delirium management practice of approaching from the front and notifying Janet of their presence. ](if:$npi1_staff is true)[The ANUM rearranges rostering for consistent nursing care of Janet over the next few days. ] (if:$npi1_cam is true)[Nursing staff implement a regular schedule of CAM scores to monitor for progression or resolution of Janet's delirium. ](if:$npi1_orient is true)[Janet is frequently oriented to the date/time and her location, and a large clock and calendar are placed at her bedside. ](if:$npi1_cannularemove is true)[Since Janet is only on oral medications, and is eating and drinking well, her IV cannula is removed.]
(set: $deliriumnpidone to true)
---
[[Proceed->1-pt2-prefinal]]]
---''EBM Tips: Non-pharmacological management of delirium''
Therapeutic Guidelines provides an excellent, 'on the go' section on <a href="https://tgldcdp.tg.org.au/viewTopic?topicfile=delirium&guidelineName=Psychotropic&topicNavigation=navigateTopic#toc_d1e506" target="_blank" rel="noopener"> non-pharmacological management approaches of delirium.</a>
In addition,''a 2016 Cochrane review by Siddiqi et al. entitled, <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005563.pub3/full" target="_blank" rel="noopener">"Interventions for preventing delirium in hospitalised non‐ICU patients"</a>'' found strong evidence in support of "multi-component interventions" to prevent delirium by targeting delirium risk factors, although the benefit was less clear for patients with pre-existing dementia.
//We found multi‐component interventions reduced the incidence of delirium compared to usual care (''RR 0.69, 95% CI 0.59 to 0.81''; seven studies; 1950 participants; moderate‐quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre‐existing dementia, the effect of multi‐component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low‐quality evidence).//
These interventions were varied between studies, but according to the authors,
//Preliminary evidence for the content of multi‐component interventions suggests that they should include as a minimum: staff education; individualised care (sometimes referred to as person‐centred care); re‐orientation at frequent intervals; and early mobilisation, but this needs further investigation. These areas are familiar aspects of care but are currently poorly and unreliably delivered.//
---
(link-undo:"Go Back")
---You get busy with other ward jobs when you are called by nursing staff looking after Janet. They report that she is frequently passing urine and appears to be in discomfort when micturating. They would like you to review or consider prescribing empiric therapy for a UTI.
Looking back on a urine dipstick performed earlier, you note + leuk and + nitrites. Given the clinical scenario, you feel it is reasonable to treat empirically for a UTI.
---
[[Continue->1-pt2-abx]]
---Janet shows a steady improvement from her UTI and resulting delirium. She engages well with allied health staff and is discharge to a GEM (Geriatic Evaluation and Management) rehabilitation ward for ongoing post-operative care.
After some weeks, you find an ornate ''$playerfavcolour'' box of chocolates in the doctor's room on the ward with the following card:
(b4r:"double")+(b4r-size:5)+(b4r-colour:white)[//''Dear Dr. $playerlastname,''
Thank you for taking such good care of my mother, Janet. You have gone out of your way to ensure she receives the highest quality, evidence-based medical care. She is back playing bingo and dancing the waltz at her nursing home, just as she was before her fall. Even though she has Alzheimer's, she still enjoys a good quality of life. Thank you for caring.
Enjoy these chocolates - and as this is not a situational judgment test, you can eat all of them and not share them.
Kind regards,
Jacob//]
You eat one of the chocolates with a smile. Medicine can be fun and rewarding sometimes.
---
[[Continue->1b-winner]]
---(if:$deliriumnpidone is true and $utiabxdone is true)[
Well done! You have considered both appropriate treatment for an acute trigger (UTI) and appropriate management for her delirium.
---
[[Continue->1-finalthoughts]] ]
(else:)[What would you like to do next?
---
(unless:$deliriumnpidone is true)[[[Speak with the nursing staff about management strategies->1-pt2-npi]]]
(unless:$utiabxdone is true)[[[Chart antibiotics->1-pt2-abx]]]
[[Prescribe some sedatives->1-pt2-sedatives]]
[[Request nursing staff to restrain Janet->1-pt2-restrain]]
[[Leave the nurses to sort this one out->1-pt2-leavenurses]]
]
---Robert says that he was at work this morning when the collapse happened. His head and arm are feeling "really sore", maybe a 7-8 out of 10. He knows he is in the hospital and can appropriately provide the date and his full demographic details. He seems nervous.
''Episode history:''
//''Before/''//
He remembers feeling nauseated just before losing consciousness. His heart was racing "a bit" but doesn't remember a funny rhythm. The air conditioning was broken at work and it was "really hot and stuffy". He was standing on the floor in the clothing shop where he works. He recalls a table nearby where he was folding and organising display items.
He had been out at a friend's house the night before, where they had drunk "a few too many". He felt "pretty hungover" but decided to come to work anyway. He has otherwise been well recently, including nil symptoms of concern for COVID-19.
//''During/''//
He doesn't remember much apart from what colleagues and the paramedics told him. They said he went down and was "shaking occasionally". He wasn't drooling and they didn't mention any moaning sounds when he first collapsed.
//''After/''//
They said he "came to" pretty quickly and immediately recalled collapsing at work. The first thing he noticed was that his head and arm were really sore. He thought he had died, but he apparently hadn't.
His tongue wasn't sore. His colleague called for an ambulance who came quickly. They gave him some water and panadol. He has not had any vomiting.
''PMHx:''
Robert reports that sometimes he can feel a bit faint when he's been standing for a long time. He hasn't had any collapses like this before.
The only other time he's been in hospital was when he broke his collarbone on a bike accident.
He doesn't take any medications. He doesn't know of any allergies. He smokes 1/2 pack cigarettes per day and occasional marijuana. He drinks 2-3 standard drinks of alcohol most nights, but when partying can have up to 10-12 drinks. He is flatting with a friend and works full-time in retail.
---
[[Perform a physical exam->2-ED-oe]]
[[Order investigations->2-ED-ptwantsix]]
[[Prescribe medications->2-ED-ptwantsix]]
---On examination, Robert is a young, somewhat anxious male resting in the ED bed. You notice a ''$playerfavcolour'' stud earring in his left earlobe. He has a jug of water next to him which he is occasionally sipping.
Vital signs: all within normal limits. Tachycardia has settled (HR 70).
General inspection: appears well. Swelling noted on R forehead - nil erythema or bleeding.
Neuro: PEARL. Moving all limbs freely and symmetrically, with some mild discomfort with R arm movements. Cranial nerve exam unremarkable.
Heart: DHSNM
Chest: Good AE bilaterally. Clear to auscultate.
Abdo: SNT. Nil masses. BS present.
Legs: Nil oedema or erythema. Non tender calves.
Imp/ Normal examination
---
[[Order investigations->2-ED-ptwantsix]]
[[Prescribe medications->2-ED-ptwantsix]]
---What further investigations would you like to order?
''Bedside:''
(checkbox: 2bind $2_Ix_dipstick,"Urine dipstick")
(checkbox: 2bind $2_Ix_urineMCS,"urine MCS")
(checkbox: 2bind $2_Ix_urinedrug,"urine drug screen")
''Serology:''
(checkbox: 2bind $2_Ix_FBE,"FBE")
(checkbox: 2bind $2_Ix_UEC,"UEC")
(checkbox: 2bind $2_Ix_LFT,"LFT")
(checkbox: 2bind $2_Ix_CRP,"CRP")
(checkbox: 2bind $2_Ix_ESR,"ESR")
(checkbox: 2bind $2_Ix_BAC,"Blood Alcohol Level")
(checkbox: 2bind $2_Ix_bloodculture,"Blood Culture")
''Imaging: ''
(checkbox: 2bind $2_Ix_CXR,"CXR")
(checkbox: 2bind $2_Ix_XRShoulder,"XR R) shoulder")
(checkbox: 2bind $2_Ix_CThead,"CT Head")
(checkbox: 2bind $2_Ix_CTneck,"CT Cervical Spine")
(checkbox: 2bind $2_Ix_MRIbrain,"MRI brain")
(checkbox: 2bind $2_Ix_echo,"Echocardiograph")
(checkbox: 2bind $2_Ix_carotid,"Carotid duplex scan")
''Additional studies: ''
(checkbox: 2bind $2_Ix_holter,"24hr Holter monitor")
(checkbox: 2bind $2_Ix_EEG,"EEG (electroencephalograms)")
(checkbox: 2bind $2_Ix_telemetry,"Telemetry")
---
[[Continue->2-ED-ixresults]] As you mention to Robert that you will discuss with your bosses in terms of any further investigations, he becomes highly anxious.
//"I hit my head! I could have a bleed and die! Please make sure to order brain imaging."//
How do you respond to Robert's concerns?
---
[[Agree and order a stat CT brain->2-CTB]]
[[Refuse, telling Robert that he is fine->2-refuse]]
[[Look for evidence to rationalise your decision->2-CTbrainEBM]]
---Congratulations! You have finished Scenario 2!
<img src=media/winner.jpg>
You have now completed all three scenarios. Well done!
---
(text-colour:red)[[[Finish->postsummary]]]
[[Repeat a scenario->ChooseScenario]]
---Double-click this passage to edit it.Hold your horses! You haven't even taken a history or done an exam - what do you want to investigate or treat for?
---
(link-undo:"Go Back")
---You attempt to order the CT brain on the ED electronic system. However, it requires you to enter a Canadian CT Head rule score before you can proceed.
---
[[Continue->2-CTbrainEBM]]
---Robert becomes more frustrated and anxious at your point blank refusal.
But I'm scared! I need to know this!
---
[[Still refuse->2-agitated]]
[[Look for evidence-based decision making support->2-CTbrainEBM]]
---(b4r:"inset","none")+(b4r-colour:orange,orange)[EBM Teaching Point: CT brain in minor head injury]
As per <a href="https://www.choosingwisely.org.au/recommendations/acem6" target="_blank" rel="noopener"> Choosing Wisely recommendations </a> from the Australian College of Emergency Medicine and Royal Australian and New Zealand College of Radiologists (RANZCR).
(b4r:"solid")+(b4r-size:2)+(b4r-colour:(hsl:240,0.8039,0.5,0.5),(hsl:240,0.8039,0.5,0.5),(hsl:240,0.8039,0.5,0.55),(hsl:240,0.8039,0.5,0.55))[Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.]
//Most head injuries presenting to emergency departments will be minor and do not require immediate neurosurgical intervention or inpatient care. Mild head injury patients can be risk stratified into ‘low’ or ‘high’ risk groups based on the presence or absence of identified clinical risk factors. Current validated clinical decision rules include the Canadian CT Head Rule (for adults) or the PECARN (Paediatric Emergency Care Applied Research Network) Tool (for children). These rules can safely identify patients who can be discharged home, without CT scanning.//
---
[[Continue->2-calcscore]]
---Using the Canadian CT Head rule, what is Robert's score?
(input-box:2bind $ctscore,"==X==",1)
Based on this assessment, does Robert meet criteria for a CT brain?
(dropdown: 2bind $CTindicated,"Yes","No")
---
[[Continue->2-calcscore2]]
---You have calculated Robert's score as ''$ctscore''. The consultant on call has also reviewed the case, and calculated a score of (text-colour:red)[''0''].
Based on this prediction tool, and the wealth of underlying evidence it is based upon, a CT brain is not clinically indicated.
---
[[Continue->2-discussresults]]
---You continue to tell Robert that "everything is fine". "After all, it's not like you have ''$playerfavdisease''!".
Robert does not respond well. He becomes more anxious and frustrated, starts yelling at the staff, and storms out of the emergency department.
You breathe a quick sigh before your consultant approaches.
//"Maybe we can have a quick chat about what just happened?"//
---
[[Continue->gameover]]
---Along with the consultant, you attend to Robert's bedside. You discuss that, based on available clinical evidence, there is no anticipated benefit that outweighs the risks of a CT brain.
Robert is initially frustrated, expressing his strong fears of having a brain bleed and dying.
However, with a gentle approach to explain your rationale, Robert is able to be convinced.
As a team, you decide that Robert appears well and requires no further ED management. He organises followup with his GP and thanks the team for their efforts.
---
[[Continue->2-winner]]
---(if:visits >= 1)[(set: $complete1b to true)]
Congratulations! You have finished Scenario 1b!
<img src=media/winner.jpg>
EBM pearls from this scenario:
(b4r:"solid","none")+(b4r-colour:orange,white)[[EBM Practice Point: Physical restraints in delirium/BPSD->EBM-restraint]]
(b4r:"solid","none")+(b4r-colour:orange,white)[[EBM Practice Point: Sedatives for delirium->EBM-sedatives]]
(b4r:"solid","none")+(b4r-colour:orange,white)[[EBM Practice Point: non-pharmacological management of delirium->EBM-npi]]
---
[[Choose another scenario->ChooseScenario]]
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</script>[(set: $playerfirstname to (prompt: "enter your first (given) name", "John"))(set: $playerlastname to (prompt: "enter your last name", "Smith"))(set: $playerfavcolour to (prompt: "enter your favourite colour", "torquoise"))(set: $playerfavdisease to (prompt: "enter your favourite disease", "acanthocheilonemiasis"))]
''Here are the details provided:''
//^^(NB. you do NOT have to use your real name; data entered are only stored locally on your device for story interactivity)^^//
''First name:'' [$playerfirstname]
''Last name:'' [$playerlastname]
''Favourite colour:'' [$playerfavcolour]
''Favourite disease:'' [$playerfavdisease]
(color:red)[''Is this correct?'']
---
[[''Yes'', continue->Overview]]
[[''No'', restart->TitleScreen]]
---''EasterEgg ACTIVATED''
---
[[Continue->ChooseScenario]]