Jim the Sim

Today we confirmed that we are indeed alive.  In small groups, we practiced finding each other's pulses, taking blood pressure, and listening to lungs.  None of us had pneumonia (crackling sounds in the lungs), no one was dehydrated (drastically different sitting and standing blood pressures), and no one was having an asthma attack (whistling).

Taking the respiratory rate requires more social grace.  The only way to determine how many breaths a person takes per minute is to watch them breathe in and out for 15 seconds or so.  Staring at a patient for that long is probably a bit Hannibal Lecter-esque, so this is the time to make small talk about their hometown or the weather and count their breaths.

After taking vitals, we were introduced to a "model patient."  Six of us gathered around the simulator, voiced by our instructor in the next room.  "I'm Jim, and I was just practicing for a triathlon and then suddenly I couldn't breathe very well."

We look at each other helplessly and start asking questions.  Has this happened before?  Are you in pain?  Are you currently taking any medications?  Do you have any other illnesses?  Do you drink or do drugs?  His blood oxygen levels are getting dangerously low, so we quickly give him an oxygen mask.

Jim apparently had asthma and an inhaler, but "I lost it a long time ago."  Okay.

Then, "You guys are doctors, right?  Aren't docs always using stethoscopes?"  Hint, hint.

It takes the six of us a bunch of minutes to confirm crackling in his lungs.  Is it asthma?  An obstruction?  Pneumonia?  Let's get a chest x-ray.  "What's going on?" Jim asks.  "Is it that radiation safe?  I want to have kids."  It's hard to talk and think; throughout the exercise, we periodically forget to clue Jim in on all the procedures we're about to do on him or how he feels afterward.  (Another group was seconds away from sticking a chest tube into their conscious patient when one of them asked, "Oh, should we tell her what we're doing?")

The results pop up on a screen, and of course we have no clue how to interpret them.  Time to get the radiologist on the phone (also voiced by our instructor).

 "What's your patient's name?" he asks.  "Jim..."  Hmm, maybe we should've gotten a last name.

Jim's lungs are hyperinflated, a sign of an asthma attack.  Soon we are giving Jim an albuterol inhaler and he is breathing better.

His heart rate is still slightly elevated, though.  Is it just anxiety or something more?  Today, we have unlimited resources, so we ask for an EKG (the exercise is not a simulator for real world cost-effectiveness, apparently).  We get a cardiologist on the phone.  Why did you order this?  "His pulse is a little fast," we reply, feeling a little bit like the medical students who cried wolf.  "It's okay, I need to send my kids to college," he answers.  The EKG is predictably normal.

Should we use beta blockers to depress the heart rate, or is the heart rate just a consequence that will resolve since we've resolved the initial problem?  In our limitless world, we order beta blockers.

The pharmacist calls us up.  Tell me about your patient, he says.  After we do, he says, "Just to let you know, beta blockers are contraindicated in patients with asthma.  Do you still want to give them to him?"  Hint.  Um.... nah.

After a few more tangents, Jim's primary care doctor calls and tells us that elevated heart rate is a side effect of the albuterol.  Oh.  Where do we want to send him now?

What's on the menu? we ask the nurse (our other instructor).

"The OR?" No.
"Intensive care?"  No.
"The floor?"  Maybe.
"An observation unit?"  We can watch him there for 24 hours.  Sure.

And so, half an hour and a lot of tangents later (followed by a debriefing by our instructors), Jim has been successfully treated for an asthma attack by the greenest of the green: third-day medical students.