This is a case report of a 39-year-old multigravida woman without allopathic prenatal care who, after three previous caesarean sections, attempted to deliver her fourth child at home with the help of a direct entry midwife. During labour, fetal movement and fetal heart tones became undetectable, at which time the patient was referred by the midwife to the hospital. The patient was diagnosed with uterine rupture, bladder rupture and fetal demise; she was rushed to emergency surgery. The patient's lack of allopathic prenatal care, attempt of vaginal birth after three previous caesarean sections, coupled with her desire for delivery at home, led to her complicated course. The patient related that she was never made aware that attempting a home birth after three prior caesarean sections put her at increased risk for complications, and she was also unaware that midwives could have varying levels of training.
Introduction: Delayed emergence is failure to regain consciousness following general anesthesia. It commonly involves altered mental status and respiratory compromise leading to increased morbidity, operating room delays, and increased cost. Causes include residual anesthetics, pharmacologic actions, surgical complications, neurologic events, endocrine disturbances, and patient-related factors. Pseudocholinesterase deficiency is an important consideration in delayed emergence. These patients are unable to effectively metabolize the muscle relaxants succinylcholine and mivacurium, leading to prolonged paralysis following administration. Methods: This simulation exercise is designed for medical students, student nurse anesthetists, and resident physicians. It is a 1-hour small-group learning activity centered upon a single patient encounter. We employ this exercise using an anesthesiology resident physician to proctor, a simulation technician to program and run, and a faculty anesthesiologist to mentor each session. It is intended to reinforce required reading assignments and improve the approach to delayed emergence from anesthesia. The debriefing includes discussion of risk-reduction strategies for incorporation in clinical practice. This exercise is easily reproduced using modern simulation mannequins without specialized programming. Results: Learners provided evaluations of their experience participating in the exercise, and resident physicians evaluated their experience proctoring the sessions. Responses were positive, and constructive criticism led to modifications to the exercise after development. Discussion: We use this exercise as an educational opportunity for medical students rotating clinically in our department. Medical students are paired with resident physicians for scenario development and work with faculty to produce valuable educational activities that benefit the entire department.
Introduction:Handoffs have been shown to be a potential cause of communication failures, leading to possible inefficiencies and patient harm. We noticed that our CA-1 residents were struggling with patient handoffs and designed this simulation to improve their handoff skills. Methods: This anesthesiology-specific simulation introduced learners to the perioperative handoff process. We designed it for anesthesiology learners, including junior residents, medical students, and student nurse anesthetists. The simulation centered upon an anesthesiology resident taking care of an ICU patient and handing that patient off to another anesthesiology provider, who took the patient to the OR. We charged learners with reviewing the patient's history and hospital course and giving a complete handoff. We evaluated learners on the completeness and quality of the handoff, as well as on their performance during the session. Results: Twenty-seven learners participated in this handoff simulation. The participants reported that the simulation improved their understanding of the anesthetic implications of medical conditions and gave them a better understanding of the essential elements of a handoff. Learners also indicated that the debriefing portion of the simulation was effective in filling some of their medical knowledge gaps and improving their handoff skills. Discussion: This simulation was found to be an effective educational experience for our CA-1 and CA-3 residents, medical students, and student nurse anesthetists. Feedback was positive from all learners. As a result, this simulation will be implemented in the early learning curriculum for all of our CA-1 residents.
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