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You are a physician in the Emergency room at St. Normal Hospital. Your specialty is radiology. You are the doctor who reads CT scans, MRI’s, PET scans, angiograms. You have been a doctor for some time now, and are interested in becoming chief of staff at the hospital. Your “performance” here may help determine whether or not you get this prestigious role.

The POINTS that you gain in each scene will help the selection committee decide whether or not you are a good person for the job! The way to gain the most points is to get the correct answer on the first try. To do this, you’ll need to do a bit research before submitting a response.

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EMR Doctor Notes EMRPatient History

Doctor NotesProtocol

The protocol: This tab lets you know what actions you need to take. Consider this your directions on what to do next.

Questions that you must respond to will be found here.

doctor, can access the information at any time. Here is a sample of what that computer screen looks like. Mouse over different portions of the screen to learn how each section will help you.

St. Normal hospital has all its patient files (vitals, history, test results) and protocol (the order in which certain tests should be done when) located on a local intranet. A computer on a rolling stand is located by each patient bed where you, the patient’s

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The “Tell Me More Button” will send you to a specific spot in the EMR. Use this to help you make decisions before submitting answers.

Images from exams will be shown here.

Dr. Notes: After you have ordered tests and made decisions regarding a patient, a brief explanation of what was done and why will be added automatically. Use this to review what you have done as you complete each scene.

Electronic Medical Record: Use this to learn details regarding the procedures and tests you will be choosing in order to help your patients. You will use the EMR often-particularly before ordering a test or making decisions about your patient.

Patient History: Gives patient history and test results..

Click Here to Begin!

Click this “Go” button once you’ve chosen a response to the question.

http://video.google.com/videoplay?docid=336848560392331352&q=ct+angiogram&hl=en

Beep! Beep! Beep!

Your pager goes off and indicates that you are being called to a suspected stroke case that is coming into the

Emergency Room (ER) from an ambulance. You will meet the

neurosurgeon, as well as the ER doctor there to assess the situation as soon as the ambulance arrives. So you hurry off

to the ER, ready to start your day!

Hospital Stroke Module

Scene A

Doctor Notes EMR Patient History

ProtocolProtocol Doctor Notes

Descriptions & Actions

Help & Reference Materials

Scene A

1. Check patient vitals, symptoms and history. (Hint: Click patient history tab above.)

a. Participant clicks on Patient history tab

b. History is given

c. Once they’ve gone to that link, the second protocol directions come up.

Act 1

Next Act

Patient History• Patient name: Shawn Idieh Jones• Patient age: 45• Medications patient has taken in the last 2 weeks:• carvedilol-brandname Coreg (a blood pressure medicine)• Misc. Behaviors: smoker, non-drinker, lifts weights three times a

week.• Family history of:

• Heart disease • Cancer • Diabetes

• Symptoms: (compare to symptoms in EMR)– When Shawn, a farm mechanic, was working on a combine, he

suddenly got the most severe headache he had ever had. He began throwing up and sweating profusely. He was able to call his wife, who in turn called an ambulance and met him at the hospital. He is unconscious as he arrived in the ER.

• Vitals:• Blood Pressure: 149/90• Pulse: 98 beats per minute

Back to ER





Scene A

1. Check patient vitals, symptoms and history.

a. Participant will be reviewing patient history, and filling in radio buttons.

b. All should be selected except inactive. Feedback should be individualized —see details in template.

c. Once participant gets the correct answer & feedback automatically go to next act.

Act 2

2. Determine which high risk factors the patient has for stroke. (Hint:

Review patient history)

Click all that apply!

• high blood pressure

•Heart disease

•Inactive

•Smoking

•Diabetes

•High cholesterol

Next Act






Scene A


Act 3

2. Determine which high risk factors the patient has for stroke.

3. Determine whether or not treatment will help or hinder the patient, by using the NIH stroke scale score. Get ER Docs help. (Make it link)

a. A pop up of the face of the ER doctor gives the stroke score. Participant should still be able to access the question as well as the EMR & Tell me more buttons

b. Correct answer: “Yes.” Feedback details are in the template.

c. Once participant gets the correct answer & feedback automatically go to next act.

•No, don’t give treatment: patient will recover without intervention.

•Yes, give treatment.

•No, don’t give treatment: patient is too severe for treatment.

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Description of NIH Stroke Scale Scores

The NIH Stroke Scale Score was 17. What do you think Dr. (participant’s last name)? Should we treat this patient or not?

The ER doctor pipes in…

Close window

Next Act


The NIH Stroke Scale Score is 17. What do you think Dr. (participant name entered here) should we treat this patient or not?” Hint: - The Electronic Medical Record will help you

decipher the NIH Score.

• Sorry, Be sure to read in the EMR, how to decipher the NIH Stroke Scale score.

Return to the ER

Feedback example screen

The NIH Stroke Scale Score is 17. What do you think Dr. (participant name entered here) should we treat this patient or not?” Hint: - The Electronic Medical Record will help you

decipher the NIH Score.

• Correct, The NIH score was 17, which is in between 4-22. This makes the patient a perfect candidate for treatment.

Return to the ER


EMR & Tell Me More Button

• NIH Stroke Scale Scores:• Basic Description:• Interpreting Scores:

– 1-3 = No treatment, patient will recover without intervention

– 4-22 = Give treatment: patient will benefit from intervention

– Higher than 22 = give no treatment: patient is too severe for treatment

Scene A: Act 3

Back to ER





Scene A Act 4


2. Determine which high risk factors the patient has for stroke.

3. Determine whether or not treatment will help or hinder the patient.

4. Determine what type of stroke the patient had.

Ischemic

Hemorrhagic

Tell me more

a. Participant uses EMR & Tell me more button to learn about the differences between the 2 types of strokes.

b. Correct answer is Hemorrhagic. Feedback details in the template.

c. Once participant gets the correct answer & feedback automatically go to next act. Next Act

Descriptions of Ischemic and Hemorrhagic strokes


Determine what type of stroke the patient had.

• Incorrect: Compare the stroke symptoms of Ischemic and Hemorrhagic stroke in the EMR.

Return to the ER


Determine what type of stroke the patient had.

• Correct: Mr. Jones most likely had a hemorrhagic stroke because the stroke symptoms did NOT include weakness or numbness of the face, but DID include nausea, vomiting, and loss of consciousness.

Return to the ER



• Difference Between Ischemic & Hemorrhagic strokes• Ischemic stroke symptoms: (83% of all strokes): Occurs when a blood

vessel contains a clot– Sudden severe headache– Sudden weakness or numbness of the face and extremities (usually to one side)– Loss of speech or difficulty understanding speech– Sudden dimness or loss of vision– Unexplained dizziness or sudden falls, particularly if accompanied with the above

symptoms. • Hemorrhagic stroke symptoms: (only 17% of all strokes): Occurs when a

blood vessel ruptures causing blood to leak into the brain. – Sudden severe headache– Nausea– Vision impairment– Vomiting– Loss of consciousness

Scene A: Act 4

Back to ER

Dr. ________’s Notes

• #2. Patient has many of the risk factors associated with stroke: high blood pressure, heart disease, smoking, diabetes, and high cholesterol.

• #3. NIH Stroke Scale Score Results: NIH score was 17, which is in between 4-22. This makes the patient a perfect candidate for treatment.

• #4. Type of stroke: Mr. Jones most likely had a hemorrhagic stroke because the stroke symptoms did NOT include weakness or numbness of the face, but DID include nausea, vomiting, and loss of consciousness.

• #5. Primary Diagnostic Test: We are ordering a CT scan instead of a MRI or PET scans because a CT scan will show us if the patient has bleeding in his brain in the shortest amount of time.

For Scene A

Back to ER

Editor’s Note: The notes should not be added all at once, but only after participants reach the correct responses.





Scene A Act 5

1. Check patient vitals, symptoms and history. 2. Determine which high risk factors the patient has for stroke. 3. Determine whether or not treatment will help or hinder the patient.4. Determine what type of stroke the patient had.

Tell me more

a. Participants will use the EMR or Tell me more button to learn about the different tests.

b. Correct answer is CT scan: Feedback details in template.

c. Once participant gets the correct answer & feedback go to final scene screen.

5. What test should be done to confirm your diagnosis?

•MRI

•PET scan

•CT scan

Descriptions of the three types of diagnostic tests.

Last screen


What test should be done to confirm your diagnosis?

• Correct: A CT scan will show us if Mr. Jones has bleeding in his brain in the shortest amount of time.

Return to the ER



• Incorrect: A PET scan will show us brain functioning but not anatomy. Look at MRI and CT scan in the -EMR

Return to the ER



• Incorrect: Mr. Jones’ symptoms started an hour ago and an MRI will take 45-60 minutes, leaving us little time to treat him. Look at CT scan and PET scan in the - EMR to se if you can find a better test.

Return to the ER



• MRI– What types of images it creates– When the test is best utilized

• CT– What types of images it creates– When the test is best utilized

• PET scan– What types of images it creates– When the test is best utilized

Scene A: Act 5

Back to ER Scene A

Back to ER Scene B

Congrats Dr. ________ !• You’ve completed the first step of treatment

for the patient Mr. Jones. • Your total score for this scene is 25/25 You

are off to a great start! Continue using the EMR and patient history before you make any decisions regarding your patient, and the committee looking for a chief of staff might just take a second look at your nomination!

• Remember…Your instructor may want you to print this page.

Editor’s note: This is just a sample of what this page would say! See template for other options.


Scene B

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Run Ct Scan

EMRProtocol Doctor Notes

1. Run CT Scan

Description/Actions:

a. Student clicks on Scan button

b. Patient enters CT machine

c. Move to Act 2

Help/Reference Materials:

How a CT scan works

Scene B, Act 1

Patient History

Next Act

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M

Subarachnoid Hemorrhagic (SAH) stroke

Non-subarchnoid Hemorrhagic (nSAH) stroke


a. CT results appear on computer along with diagnostic options

b. If student chooses SAH stroke, move to Act 3

c. If student choose nSAH stroke, a window should appear showing what a CT scan of an nSAH stroke looks like


CT scan of nSAH stroke

How to read a CT scan

Normal brain CT

Scene B, Act 2

Protocol EMR Patient HistoryProtocol

Doctor Notes Patient History

Tell me more

1. Run CT Scan

2. Confirm primary diagnosis

Next Act

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3. Determine the cause of the bleed


Causes of hemorrhagic strokes and the corresponding treatments.

Scene B, Act 3

Patient History

What is causing thisbrain hemorrhage?

Based on your research, will you…

• Send the patient for neurosurgery?

• Order a second diagnostic test?

Actions:

A. Student determines probably cause of hemorrhage by reading about causes of SAH stroke in VMT.

B. Student chooses desired course of action. Tell me more

1. Run CT Scan


Next Act

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4. Order a second diagnostic test


Definitions/examples of MRI, PET scans and CT angiograms with their commons uses.

Scene B, Act 4

Patient History

Secondary test options:

• MRI • PET scan • CT angiogram

Actions:

A. Student chooses desired test to find aneurysm.

B. If chooses correctly, moves to Scene C

Tell me more

3. Determine the cause of the bleed

1. Run CT Scan


Last Screen

Dr. _______’s Notes

• Ordered CT Scan– Faster– Can find bleed in brain– Less expensive

Return to ER

Hospital Stroke ModuleIntroduction

Prepared by Elisa Palmer & Darci Harland

How a CT Scan Works

Return to ER

EMR & Tell Me More ButtonScene B: Act 1


• Ordered CT Scan: faster, can find bleed in brain, less expensive

• Subarachnoid hemorrhagic (SAH) stroke diagnosed

Return to ER

Bleeding

• How to read a CT scan

• Normal brain CT

• Descriptions of nSAH and SAH strokes

• CT scan of nSAH stroke

• CT scan of SAH stroke


Back to ER

SAH stroke

• Correct! The bright white areas indicate a bleed in the subarachnoid space. Great job Dr _______! Proceed!

• Return to ER

Bleeding


nSAH Stroke

• CT scan of nSAH stroke

• Does your patient’s CT scan match this one? Try again!

• Your patient’s CT scan

• Return to ER



• Causes of SAH hemorrhagic strokes and their treatments

Back to ER

Neurosurgery for Mr. Jones?

• Sorry, Mr. Jones’s SAH stroke if probably due to an aneurysm since there is no recent trauma in his medical history. Therefore, surgery is not a good choice for him. Try again!

Return to the ER


A second test for Mr. Jones?

• Correct! Mr. Jones’s SAH stroke if probably due to an aneurysm since there is no recent trauma in his medical history.

• Now, you must determine the best test for to find Mr. Jones’s aneurysm. Hurry, the clock is ticking!

Return to the ER


Dr. _____’s Notes – Act 3

• SAH stroke is probably due to an aneurysm since there is no trauma in Mr. Jones’ recent patient history

Back to ER Act 3

CT Angiogram for Mr. Jones?

• Correct! A CT Angiogram will allow you to find the location of the suspected angiogram. Proceed to the CT Angiogram room!


Last Screen

An MRI for Mr. Jones?

• This patient’s symptoms started over an hour ago and an MRI will take 45-60 minutes. This may not leave you enough time for treatment. Try again!


A PET scan for Mr. Jones?

• PET scans are normally used to show brain functioning, not cardiovascular anatomy. Try again!


Dr. ________’s Notes

• CT angiogram ordered in order to determine the location of the aneurysm. MRI rejected due to time issues and PET scan rejected because it would show brain functioning, not brain anatomy.

Congrats Dr. ________ !• You’ve completed the second step of

treatment for the patient Mr. Jones. • Your total score for this scene is 15/15: You

are off to a great start! Continue using the EMR and patient history before you make any decisions regarding your patient, and the committee looking for a chief of staff might just take a second look at your nomination!

• Remember…Your instructor may want you to print this page.

Editor’s note: This is just a sample of what this page would say! See template for other options.


Scene C

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• Run CT Angiogram


1. Perform CT angiogram


Student clicks on “Run CT Angiogram” and video pops up, showing a patient having a CT angiogram scan. Move to Act 2.

EMR:

Description of how and why CT Angiograms are done.

Scene C, Act 1

Patient History

Tell me more

Next Act


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Choose a course of treatment:

Clip the aneurysm

Coil the aneurysm

Description/Actions:CT angiogram results

show that the patient has an aneurysm in the anterior communicating artery. Student must choose to either clip or coil the artery.

Electronic Medical Record:Brain blood vessel anatomyInformation about clipping aneurysmsInformation about coiling aneurysms

Scene C

Act 2

Protocol EMR Patient HistoryProtocol

Doctor Notes Patient History

Tell me more


2. Determine course of treatment

Next Act

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Insert a coil into the aneurysm.


Electronic Medical Record:

Video of emoblization

(coiling) process.

Scene C, Act 3

Patient History


A. Student clicks on “coil the aneurysm”.

B. Coiling procedure video or simulation is shown.



3. Perform embolization (coiling) on the aneurysm. Tell me more

Next Act

http://brainavm.oci.utoronto.ca/swf/aneurysm_coiling.html

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EMR:HHH therapyVasospasms (causes and treatments)

Scene C, Act 4

Patient History

Coiling of aneurysm was successful.

Send patient to ICU with orders for HHH therapy and vasospasm monitoring

Student clicks on “Send patient to ICU”

Tell me more

4. Send patient to ICU



3. Perform embolization (coiling) on the aneurysm.

Last Screen

http://images.google.com/imgres?imgurl=http://www.bmc.org/neurosurgery/images/coiledaneurysmafter.jpg&imgrefurl=http://www.bmc.org/neurosurgery/jabre.html&h=113&w=135&sz=12&hl=en&start=8&tbnid=repHBSQcCWvEmM:&tbnh=77&tbnw=92&prev=/images%3Fq%3Dcoiled%2Baneurysm%26svnum%3D10%26hl%3Den%26lr%3D

http://images.google.com/imgres?imgurl=http://www.bmc.org/neurosurgery/images/coiledaneurysmafter.jpg&imgrefurl=http://www.bmc.org/neurosurgery/jabre.html&h=113&w=135&sz=12&hl=en&start=8&tbnid=repHBSQcCWvEmM:&tbnh=77&tbnw=92&prev=/images%3Fq%3Dcoiled%2Baneurysm%26svnum%3D10%26hl%3Den%26lr%3D

• Description of how/why CT Angiograms are performed.

Return to ER

EMR & Tell Me More ButtonScene C: Act 1


• CT Angiogram shows aneurysm in the anterior communicating artery

• Aneurysm in Anterior Communicating Artery

• Have decided to coil/embolyze the aneurysm due to the patient’s age and lack of invasiveness of this procedure.

Return to ER

http://www.yna.org/New%20Pages/NLW03.html

• Brain Blood Vessel Anatomy

• Information about Clipping Aneurysms

• Information about Coiling Aneurysms

Return to ER


Clipping Aneurysms

… Info on Coiling

Return to ER


Coiling Aneurysms

Return to ER


Coiling Aneurysms

• Insert a coil into the aneurysm. (animation)

Return to ER


http://brainavm.oci.utoronto.ca/swf/aneurysm_coiling.html

http://rope.wlsam.com/audio_player/player.html

Dr. _____’s Notes

• Aneurysm successfully coiled.

• Sent patient to ICU for recovery. Ordered HHH therapy and monitoring for vasospasms.

Congratulations!

• You have successfully treated Mr. Jones within the necessary 3 hour time window! If you have scored a ___ or higher, you are still in the running to become Chief of Staff – great job! If you have scored lower than a ___, perhaps the next stroke patient to come through the doors of St. Normal Hospital will have better results. Also, please realize that Mr. Jones’ journey is not over. He will have a 10-14 day stay in the ICU (where the rate of mortality from strokes is very high 2-12 days following the initial stroke) and then undergo physical therapy.

• HHH Therapy

• Vasospasms


Back to ER

Clip the Aneurysm

• This procedure is highly invasive and should only be done when the aneurysm is located close to the surface of the brain and on younger patients. Please think carefully before proceeding with this procedure on this patient.

Return to Patient


Coil the Aneurysm

• Correct! This procedure is much less invasive and a better choice for this patient. Go forward with your treatment of this patient.

Return to patient


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