VHA SimLEARN
Clinician Credits Simulation Training for Helping Diagnose Serious Condition
By Gerald Sonnenberg
EES Marketing and Communication
SYRACUSE, N.Y. – The VHA SimLEARN National Simulation Center (NSC) provides VA clinicians with a wide variety of courses designed to improve their skills, as well as provide our Veterans with an even higher level of care. Oftentimes, the public benefits from the care of a VA physician trained in an NSC course. That was the case recently when Dr. Ryan Reed, chief resident of quality and patient safety at the Syracuse VA Medical Center (VAMC) in New York was moonlighting at a local, private hospital.
“(At the VA) Part of what I do is teach residents about quality improvement (QI) and work on various QI projects around the hospital,” explained Dr. Reed. “However, this year I have also chosen to train the residents in code blue scenarios, intubation and central line placement. In addition, I wanted to be able to give the residents some skills in utilizing bedside ultrasound.”
He added that they don’t receive a lot of training on that topic during residency, so he took a Point of Care Ultrasound (POCUS) course at the NSC. POCUS is being used by non-radiologists more and more. At the NSC, this face-to-face course teaches providers basic diagnostic and procedural applications of POCUS. The curriculum consists of three components; didactics, hands-on simulation scenarios with task trainers and hands-on scenarios using standardized patients. He said that after the training he was excited to start using his new skills which, it turns out, came in handy only two days after his return. It was during a Saturday night shift where Dr. Reed moonlights when he received a call from the emergency department (ED).
“We work in pairs at night, with the one hospitalist taking pages directly from the ED and the floors, while the other hospitalist strictly does admissions. I was informed by my coworker that the ED called on a man for simple ACS (acute coronary syndrome) rule out, and that I should go admit him,” he said.
Dr. Reed described the patient as a 58-year-old man with no known history of healthy concerns or medications. The man came in to the ED because he felt lightheaded and suddenly short of breath; almost passing out before he sat down to relieve the dizziness.
“Since I was told this was an ACS rule out case, I asked about chest pain,” said Dr. Reed. “He denied having any chest pain that day, but he then said he had gone to another hospital in the area one week before for chest pain. At that time, they drew some blood and took an EKG, but ultimately found nothing and sent him home. He also quickly mentioned that he was told he had a little fluid around his heart.”
Dr. Reed said the patient’s blood pressure was 110 over 70 initially, but after looking at his chart in his room he noticed that the man had “many systolic blood pressure recordings in the 80s and 90s, as well as one in the 60s.” He noticed that it showed very low voltage and explained that all these signs together led him to think that the patient could have a pericardial effusion (excess fluid between the heart and the sac surrounding the heart, known as the pericardium) that was leading to an emergency condition called a cardiac tamponade. This a clinical syndrome caused by the accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise.
“I grabbed the ultrasound machine in the ED and, using my new skills I recently acquired at my POCUS training, I quickly obtained a nice subcostal, four-chamber view,” said Dr. Reed. “As soon as I obtained the image, there was a clearly visible large pericardial effusion.”
He then called cardiology to evaluate the patient. The cardiologist on call agreed with the assessment and the patient was taken for immediate pericardiocentesis to remove the fluid.
“I followed up on the patient’s chart a few nights later and found out that over 500 cc’s (or cubic centimeters) of fluid were removed during the pericardiocentesis,” said Dr. Reed. “My bedside ultrasound skills helped me quickly diagnose a critical condition and prevented possibly dangerous delays in care. I was very pleased with the skills I have learned and very thankful that I had them at that moment.”
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