SimFridays - Appendicitis

Continuing the surgical theme today we simulated a young patient with a perforated appendix.

Next week's SimFridays is cancelled for Christmas.  Hope everyone is able to relax and spend some time with family or friends - even if that might now be in virtual form. 

Next month the plan is for a mental health theme - if anyone has ideas of how best to approach simulation in this month please get in touch.

The simulated case: 
A 19 year old woman presented with abdominal pain during the night, and due to ED pressures she had been waiting to be assessed in majors at the time of morning handover.

What happened?
The ED team assessment in majors found her to be tachycardic and tachypnoeic, with uncontrolled pain. She had an A-E assessment followed by management of pain, fluid resuscitation and antibiotics - then the potential causes of this presentation were considered. 

What did we think? 
In debrief we discussed:

Imaging:
We talked about the considerations of using CT in this patient group. Generally, ultrasonography is preferred in young women due to the higher incidence of gynaecological cause and the radiation involved in CT. However, as discussed in the simulation, the timing of the imaging must also be considered - if there is going to be a long delay for USS then the preference might shift to CT. If there is a high suspicion of appendicitis with shock, then immediate appendicectomy may be performed however if there is diagnostic uncertainty then there is value in imaging, and the evidence suggests this does not cause additional delay in general. (ASGBI commissioning guide 2014, see p12-13).

Gynaecological vs general surgical causes:
This patient was shocked and had an empty bladder scan, therefore a urine pregnancy test had not been possible. We talked about while there is diagnostic uncertainty it may be reasonable to involve both teams. β-HCG can be added-on to blood already taken.

Simultaneous treatments:
In this case there were competing demands on our colleagues time and resources. There were paracetamol, antibiotics, fluid, and analgesia to give - and only one cannula - and there was also discussion to be had with ED seniors, radiology (+/- scan requesting), and the surgical team. Managing these priorities was a key part of the thinking in this scenario. What would be your strategy in this circumstance be?

Overnight delays:
We talked about how after the initial front-door assessment there can be delays in being seen definitively, and patients have the potential to worsen during this time. The expected benefit from having a greater number of nursing colleagues is a repeated theme from SimFridays feedback, and today this was also discussed as something that would benefit patients like these. Other feedback included having patients like this allocated to the more visible bays, or if in the corridor then under the care of an assigned nurse. 

In this simulated case the patient went on to have a CT abdomen which showed acute appendicitis with perforation, and they went to theatre.

To do:

The next time you have multiple tasks to complete, take a moment to think through your thought processes. You might instinctively know which tasks take highest priority - analyse why you know this to be the case, what would change your mind, when is this not the case etc  [  ]

If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it   [  ]


Blog by: James Keitley ED sim fellow

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For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author.