Welcome to the Diagnosis Day adventure. In order to maximize your experience and your learning, please complete the assignments below, read the information about TRAUMA and read the SCENARIO pages. You’ll be asked questions during Diagnosis Day about this information. Bring this booklet with you.
Diagnosis Day Learning Objectives:
At the conclusion of Diagnosis Day, students will
Be able to identify at least three health care careers in which they have an interest;
Be able to discuss the meaning of TRAUMA and the impact TRAUMA has on the population aged 1-50;
Be aware of the number of health care professionals who have contact with a TRAUMA victim following an accident;
Have defined and understand a minimum of 5 trauma-related, medical terms.
TIME/DATE: Diagnosis Days generally begin by 8:30am and finish no later than 3:00 p.m.
ASSIGNMENT #1: Personal research about careers in Health Care.
Here, you have a choice. You can complete the quick survey at www.healthjobsstarthere.com (accessed directly via the link or through our website at http://www.cascadeseast.org/). On this website, you answer a few simple questions and are provided with a list of possible careers which might be a good match for your interest.
Or use the website EXPLORE HEALTH CAREERS. From this site you can investigate many careers, get information on education requirements and find basic salary ranges.
No matter which choice you select, list the careers in which you think you MIGHT have an interest.
_____________________ _____________________ _________________________
ASSIGNMENT #2: Medical Vocabulary
During Diagnosis Day, you will be part of the process as patients are evaluated based on their symptoms. You need to know these terms and be ready to offer them as an explanation or course of action for the patient.
You will be divided into 3 teams. Each team needs to make sure that each of the vocabulary terms is researched by a team member. Write down the information you find below. There are many easily accessible internet sources- including Webmd and Medterms.com.
First, a note about the use of simulation manikins. We will be using high-fidelity simulation manikins. These manikins breathe, cough, and have heart, lung and bowel sounds that can be heard by stethoscope. You may have the opportunity to give IV medications, apply oxygen, and check pulses among other things.
We will try to make the scenarios as realistic as possible but, as this is an extremely expensive piece of equipment, the actions will need to be closely monitored.
We will be running 3 scenarios with each group getting to perform some unique actions for the patient. The other groups will observe.
For the scenarios to work and to get the action done in a reasonable amount of time we will be “time warping” the scenario.
Paying close attention to the controller is key to giving you the best experience possible.
For the balance of this document the term Caregiver should be seen as any of the multiple healthcare workers directly involved in treating the patient. This can include physicians, nurses, respiratory therapists, EMT/paramedics and Basic Life Support providers.
Trauma Trauma is the leading cause of injury and death among Americans between age 1 and 50. This trauma can be from accidents, assault or self-inflicted injury. In our scenario, we will treat three simulated trauma patients and help them- from the time of their accident through acute treatment and possibly through rehabilitation.
Trauma can take many forms. Among teenagers, auto accidents are the leading cause of trauma, followed by bike accidents, falls, other sports accidents, drowning, and gunshot wounds.
The initial approach to trauma follows the ABCs.
A is for airway and cervical spine control. With trauma, the patient may well be unconscious. Unconscious patients are at risk for blockage of their airway called airway obstruction. They may also have suffered damage to or a fracture of the neck. Moving the neck can damage the spinal cord. Thus, the goal is to open the airway while being sure not to damage the spinal cord.
The signs of airway obstruction may be a snoring sound or no sound at all. To open the airway, the caregiver will try to keep the head straight and will try to move the jaw upward so as to move the tongue out of the airway. The EMTs will then try to stabilize the neck with their hands and will later stabilize the neck using a cervical collar or a back board.
B is for breathing. With trauma or head injury, the patient may be so deeply unconscious that he/she is no longer breathing. The caregivers will carefully listen for air movement and will look for the chest to rise as a sign of adequate breathing. If the breathing is not adequate, they may use a breathing bag and mask to assist the breathing. If the patient does not quickly respond to “bagging”, they may try to insert a breathing tube into the lungs to further assist the breathing. Even if the breathing is normal, the caregiver may give additional oxygen. Typical breathing rate for adult patients is 14-20 breaths per minute.
C is for circulation. The caregiver will check for a pulse. A normal pulse will be strong, regular and at a rate of 70 to 100 beats per minute. A weak pulse can mean low blood pressure and shock. An irregular heart rate may suggest an electrical problem or arrhythmia. A very fast pulse suggests early shock. A slow pulse may be associated with increased pressure on the brain. The caregiver may further check for circulation by checking the blood pressure, monitor the heart using an electrocardiogram and insert an IV to give the patient fluids, if necessary.
In the instance where the patient is coming from the field after the caregivers have assessed and addressed the ABCs, they will contact the Emergency Department (ED) so that it will be ready for the patient. In the hospital, the trauma team will be assembled and assignments will be determined based on the anticipated needs of the patient.
On the trip to the hospital, the field caregivers will continue to gather more information and will continue to monitor the vital signs. In the ED the field caregivers will give a very concise but more extensive than the earlier radio report to the ED staff about the patient.
The ED crew will then take over the case. When treating a trauma patient, the trauma team will generally consist of a doctor, several nurses, a respiratory therapist, a lab technician, a radiology technician(s) and the chaplain. Additional members are called in depending on the level of the trauma and the facility’s policies.
The trauma team will re-assess the ABCs. If those are stable, the team will then do a full head to toe assessment, looking for other injuries. They may do certain tests, including:
Blood Pressure- a blood pressure cuff measures the blood pressure. A normal blood pressure in an adult is greater than 100/60. (It may be slightly lower in pre-teens)
Temperature With trauma, the patient may be cold, especially if he/she has been wet or outside for a prolonged amount of time.
Oximetry Sensor- a laser probe will be attached to the finger to check the oxygen level of the blood. A normal oxygen level will be more than 94%. Lower levels can suggest injury to the lungs.
Cardiac Tracing- Electrodes are attached to the skin and a cardiac tracing is obtained. This is a very accurate way to measure heart rate and rhythm.
Blood work – The blood tests can be used to determine the presence of bleeding, organ injury, or underlying issues that can impact the resuscitation and recovery. Typically patients are also tested for the presence of drugs and alcohol so that the team is aware as this can cause complication with medications. Females of child-bearing age are tested for pregnancy.
The physical assessment will look for injuries that may have been sustained in the accident. The doctor will feel the head to look for swelling, lacerations (a jagged wound or cut), or signs of a skull fracture. He will look at the ears to be sure that the eardrums are clear. With a severe head injury or particular skull fracture, there may be blood coming from the ears. The ED doctor will look at the eyes. When normal, the pupils will be equal and will constrict equally to light. With head injury or pressure on the brain, the pupils may be unequal or may not react to light.
The doctor will carefully check
the chest for injuries and will listen for breath sounds
the abdomen, looking for bruising or tenderness
the extremities, looking for deformities, bruising or tenderness
for injuries to the face and jaw
The doctor will then do a neurologic exam, looking for the level of consciousness, muscle tone, and reflexes.
Almost any part of the body can be injured in trauma. The most important injuries include:
Head Trauma- Head trauma causing brain injury is the leading cause of death and permanent disability in trauma.
Anatomy and Physiology- To understand head trauma, we need to review the anatomy of the brain and skull. The brain is soft, almost gelatinous. The blood supply to the brain comes up through the carotid arteries, supplies the brain and then drains in veins largely on the outside of the brain. Covering the brain and the nerves is a tough covering called the dura mater. Outside the dura are the temporal arteries. Covering this is the skull that forms a closed system. In the normal state, the pressure inside the skull is low letting the blood flow easily from the arteries, through the brain and then draining easily into the veins.
Pathophysiology- With head trauma, several things can go wrong.
Head trauma can cause bleeding from the veins on the surface of the brain, causing a hematoma or clot underneath the dura called a subdural hematoma. This subdural hematoma can cause an increase in the pressure inside the skull. With increased pressure, the blood cannot easily flow and the brain may suffer damage from the increased pressure and decreased blood flow. Subdural hematomas are treated by surgery to remove the clot and stop the bleeding.
At other times, a direct blow over the temporal artery can cause disruption of the temporal artery, causing bleeding in the space between the dura and the skull, called an epidural hematoma. This type of hematoma can build up very quickly and cause severe pressure on the brain and blood vessels. Treatment includes immediate surgery to remove the clot and stop the bleeding.
With a blow to the head, the brain can suffer a concussion. We don’t fully understand what happens during a concussion, but we think rapid acceleration and deceleration of the brain can cause “shear” type injuries to the very small vessels and connections in the brain. There may be some swelling of the brain that can cause decreased blood flow. With minor concussions, the patient may not lose consciousness, but may “see stars”. With more serious concussions, the patient may have loss of consciousness and when they wake up, may have amnesia for the event. With very serious concussions, the patient may have prolonged loss of consciousness, or coma. All types of concussions do some damage to the brain. Generally the more severe the concussion, the more damage is done. Even with mild concussions, patients may have headaches, difficulty concentrating, and poor school and work performance. With severe concussions, patients may be left with personality changes, poor memory and poor problem solving. There is no specific treatment for concussion, but the patient may require supportive care like IV fluids and may require rehabilitation to regain their pre-accident abilities.
Diagnosis- Brain injuries can be best diagnosed by advanced imaging, usually CAT (CT) scanning.
Abdominal Trauma- With high velocity trauma, injury to the soft organs of the abdomen may occur, including the liver, spleen or kidneys. Each of these organs is soft and has a lot of blood flow, so that injury to these organs can cause severe abdominal hemorrhage. Doctors can diagnose abdominal trauma by physical exam, as bleeding into the abdomen can cause the abdomen to distend and become tender. They sometimes use ultrasound to look for blood in the abdomen. The most accurate way is to use CT scanning, which will be able to show damage to these organs. Treatment for the injuries will frequently require blood transfusions or surgery.
Orthopedic Trauma- Broken bones are common in trauma. Virtually any bone can be broken. The good news about orthopedic trauma is that most orthopedic trauma can be fixed. Broken bones can be diagnosed by physical exam that can show tenderness, bruising or deformity. Plain X-rays are then used to see the fracture. Broken bones can then be fixed by casting (if the fracture is not displaced), or by an operation using rods, screws and other connectors.
From the Emergency Department, the patient will go to the operating room (OR), if necessary. Many trauma patients are then monitored in the intensive care unit (ICU) until stable. With severe head trauma or orthopedic trauma, the patient may not be able to return to normal activities and may need rehabilitation to regain all of their pre-trauma functions.
Please answer the following questions, as they will be important to help you properly diagnose a patient on Diagnosis Day.
A distended and sore abdomen is a sign of which of the following?
What do the ABCs of Trauma stand for?
What is the leading cause of injury and death among Americans between age 1 and 50
What are two of the reasons that head traumas can be so severe? (ie: what can go wrong quickly)
What does an Oximetry Sensor read?
Scenarios for Diagnosis Day 2014
Car vs Bike plus Tree
Anne, Bill and Charlie- the accident victims- are all high school students in a rural community.
Bill is driving with Charlie, headed to school on a rainy, sleety morning. Charlie realizes he left his phone in his bag and really wants Bill to see the latest “cute kitten” post on Instagram. Charlie unbuckles to reach the bag in the back seat and looks for the posting. He neglects to re-buckle his seat belt.
While Bill is looking at yet another kitten posting, he veers to the right, hits a slick spot in the road. This sends the car spinning off the road. While spinning they feel and hear two distinct impacts. The last one stops the car.
Another driver witnesses the accident and sees the car first hit a cyclist, then hit a tree. The driver calls 911.
EMS arrives on the scene and finds Bill behind the steering wheel, Charlie lying face up on the floor of the back seat and Anne thrown from her bike. Community members are frantic and trying to talk to the injured youth.
The EMS responders in the initial contact will triage the patients based on injury and needs using multiple assessment tools that can be performed quickly. In this case they quickly find:
Bill appears alert and oriented to person, place, time and situation, is having some trouble breathing, hand on chest, and his left leg is angled oddly midway between the knee and ankle. His color is pale, but has strong pulses with a heart rate of 108 and is breathing at 22 breaths per minute. He is making eye contact, and responds appropriately to questions. Keeps asking where Charlie is. Bill complains of pain in his chest, left wrist and leg as well as hip.
Charlie is positioned face up on the floor of the back seat and is currently unconscious. He is breathing at a rate of 16 and has a strong pulse of 85.
Anne was riding her bike when she was struck from behind by the vehicle and is lying face up in the dirt about 15 feet from the side of the road. She is conscious but is having trouble holding eye contact or answering questions. She knows her name but that is all. She is not wearing a helmet and bystanders state they did not see one. She is breathing rapidly and has strong pulses at 120 beats per minute. She is complaining of pain in her head, back, and neck and hips.
Please answer the following questions based on the very limited information you have received so far. There are several possibilities and we do not expect you to catch every possibility.