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  1. You are a physician in the Emergency room at St. Normal Hospital. Your specialty is radiology. You are the doctor who reads CT scans, MRI’s, PET scans, angiograms. You have been a doctor for some time now, and are interested in becoming chief of staff at the hospital. Your “performance” here may help determine whether or not you get this prestigious role. The POINTS that you gain in each scene will help the selection committee decide whether or not you are a good person for the job! The way to gain the most points is to get the correct answer on the first try. To do this, you’ll need to do a bit research before submitting a response.

  2. Patient History: Gives patient history and test results.. Electronic Medical Record: Use this to learn details regarding the procedures and tests you will be choosing in order to help your patients. You will use the EMR often-particularly before ordering a test or making decisions about your patient. Dr. Notes: After you have ordered tests and made decisions regarding a patient, a brief explanation of what was done and why will be added automatically. Use this to review what you have done as you complete each scene. St. Normal hospital has all its patient files (vitals, history, test results) and protocol (the order in which certain tests should be done when) located on a local intranet. A computer on a rolling stand is located by each patient bed where you, the patient’s doctor, can access the information at any time. Here is a sample of what that computer screen looks like. Mouse over different portions of the screen to learn how each section will help you. Tell me more Protocol Patient History Doctor Notes Doctor Notes EMR EMR Images from exams will be shown here. The protocol: This tab lets you know what actions you need to take. Consider this your directions on what to do next. The “Tell Me More Button” will send you to a specific spot in the EMR. Use this to help you make decisions before submitting answers. Questions that you must respond to will be found here. Tell me more Click this “Go” button once you’ve chosen a response to the question. Click Here to Begin!

  3. Beep! Beep! Beep! Your pager goes off and indicates that you are being called to a suspected stroke case that is coming into the Emergency Room (ER) from an ambulance. You will meet the neurosurgeon, as well as the ER doctor there to assess the situation as soon as the ambulance arrives. So you hurry off to the ER, ready to start your day!

  4. Hospital Stroke Module Scene A

  5. Help & Reference Materials Protocol Doctor Notes EMR Patient History Protocol Descriptions & Actions Scene A Act 1 Doctor Notes 1. Check patient vitals, symptoms and history. (Hint: Click patient history tab above.) • Participant clicks on Patient history tab • History is given • Once they’ve gone to that link, the second protocol directions come up. Next Act

  6. Patient History • Patient name: Shawn Idieh Jones • Patient age: 45 • Medications patient has taken in the last 2 weeks: • carvedilol-brandname Coreg (a blood pressure medicine) • Misc. Behaviors: smoker, non-drinker, lifts weights three times a week. • Family history of: • Heart disease • Cancer • Diabetes • Symptoms: (compare to symptoms in EMR) • When Shawn, a farm mechanic, was working on a combine, he suddenly got the most severe headache he had ever had. He began throwing up and sweating profusely. He was able to call his wife, who in turn called an ambulance and met him at the hospital. He is unconscious as he arrived in the ER. • Vitals: • Blood Pressure: 149/90 • Pulse: 98 beats per minute Back to ER

  7. Help & Reference Materials Protocol Doctor Notes Patient History Protocol Descriptions & Actions Scene A Act 2 Doctor Notes EMR Click all that apply! 1. Check patient vitals, symptoms and history. • Participant will be reviewing patient history, and filling in radio buttons. • All should be selected except inactive. Feedback should be individualized —see details in template. • Once participant gets the correct answer & feedback automatically go to next act. • high blood pressure • Heart disease • Inactive • Smoking • Diabetes • High cholesterol 2. Determine which high risk factors the patient has for stroke.(Hint: Review patient history) Next Act

  8. Help & Reference Materials The ER doctor pipes in… The NIH Stroke Scale Score was 17. What do you think Dr. (participant’s last name)? Should we treat this patient or not? Protocol Doctor Notes Patient History Protocol Descriptions & Actions Close window Scene A Act 3 Description of NIH Stroke Scale Scores • No, don’t give treatment: patient will recover without intervention. • Yes, give treatment. • No, don’t give treatment: patient is too severe for treatment. Doctor Notes EMR 1. Check patient vitals, symptoms and history. • A pop up of the face of the ER doctor gives the stroke score. Participant should still be able to access the question as well as the EMR & Tell me more buttons • Correct answer: “Yes.” Feedback details are in the template. • Once participant gets the correct answer & feedback automatically go to next act. 2. Determine which high risk factors the patient has for stroke. Tell me more 3. Determine whether or not treatment will help or hinder the patient, by using the NIH stroke scale score. Get ER Docs help. (Make it link) Next Act

  9. Feedback example screen The NIH Stroke Scale Score is 17. What do you think Dr. (participant name entered here) should we treat this patient or not?” Hint: - The Electronic Medical Record will help you decipher the NIH Score. • Sorry, Be sure to read in the EMR, how to decipher the NIH Stroke Scale score. Return to the ER

  10. Feedback example screen The NIH Stroke Scale Score is 17. What do you think Dr. (participant name entered here) should we treat this patient or not?” Hint: - The Electronic Medical Record will help you decipher the NIH Score. • Correct, The NIH score was 17, which is in between 4-22. This makes the patient a perfect candidate for treatment. Return to the ER

  11. EMR & Tell Me More Button Scene A: Act 3 • NIH Stroke Scale Scores: • Basic Description: • Interpreting Scores: • 1-3 = No treatment, patient will recover without intervention • 4-22 = Give treatment: patient will benefit from intervention • Higher than 22 = give no treatment: patient is too severe for treatment Back to ER

  12. Help & Reference Materials Protocol Doctor Notes Patient History Protocol Descriptions & Actions Scene A Act 4 Descriptions of Ischemic and Hemorrhagic strokes Doctor Notes EMR 1. Check patient vitals, symptoms and history. • Participant uses EMR & Tell me more button to learn about the differences between the 2 types of strokes. • Correct answer is Hemorrhagic. Feedback details in the template. • Once participant gets the correct answer & feedback automatically go to next act. 2. Determine which high risk factors the patient has for stroke. 3. Determine whether or not treatment will help or hinder the patient. Ischemic Hemorrhagic 4. Determine what type of stroke the patient had. Tell me more Next Act

  13. Feedback example screen Determine what type of stroke the patient had. • Incorrect: Compare the stroke symptoms of Ischemic and Hemorrhagic stroke in the EMR. Return to the ER

  14. Feedback example screen Determine what type of stroke the patient had. • Correct: Mr. Jones most likely had a hemorrhagic stroke because the stroke symptoms did NOT include weakness or numbness of the face, but DID include nausea, vomiting, and loss of consciousness. Return to the ER

  15. EMR & Tell Me More Button Scene A: Act 4 • Difference Between Ischemic & Hemorrhagic strokes • Ischemic stroke symptoms: (83% of all strokes): Occurs when a blood vessel contains a clot • Sudden severe headache • Sudden weakness or numbness of the face and extremities (usually to one side) • Loss of speech or difficulty understanding speech • Sudden dimness or loss of vision • Unexplained dizziness or sudden falls, particularly if accompanied with the above symptoms. • Hemorrhagic stroke symptoms: (only 17% of all strokes): Occurs when a blood vessel ruptures causing blood to leak into the brain. • Sudden severe headache • Nausea • Vision impairment • Vomiting • Loss of consciousness Back to ER

  16. Editor’s Note: The notes should not be added all at once, but only after participants reach the correct responses. Dr. ________’s Notes For Scene A • #2. Patient has many of the risk factors associated with stroke: high blood pressure, heart disease, smoking, diabetes, and high cholesterol. • #3. NIH Stroke Scale Score Results: NIH score was 17, which is in between 4-22. This makes the patient a perfect candidate for treatment. • #4. Type of stroke: Mr. Jones most likely had a hemorrhagic stroke because the stroke symptoms did NOT include weakness or numbness of the face, but DID include nausea, vomiting, and loss of consciousness. • #5.Primary Diagnostic Test: We are ordering a CT scan instead of a MRI or PET scans because a CT scan will show us if the patient has bleeding in his brain in the shortest amount of time. Back to ER

  17. Help & Reference Materials Protocol Doctor Notes Patient History Protocol Descriptions & Actions Scene A Act 5 Descriptions of the three types of diagnostic tests. Doctor Notes EMR 1. Check patient vitals, symptoms and history. • Participants will use the EMR or Tell me more button to learn about the different tests. • Correct answer is CT scan: Feedback details in template. • Once participant gets the correct answer & feedback go to final scene screen. 2. Determine which high risk factors the patient has for stroke. 3. Determine whether or not treatment will help or hinder the patient. 4. Determine what type of stroke the patient had. • MRI • PET scan • CT scan 5. What test should be done to confirm your diagnosis? Tell me more Last screen

  18. Feedback example screen What test should be done to confirm your diagnosis? • Correct: A CT scan will show us if Mr. Jones has bleeding in his brain in the shortest amount of time. Return to the ER

  19. Feedback example screen What test should be done to confirm your diagnosis? • Incorrect: A PET scan will show us brain functioning but not anatomy. Look at MRI and CT scan in the -EMR Return to the ER

  20. Feedback example screen What test should be done to confirm your diagnosis? • Incorrect: Mr. Jones’ symptoms started an hour ago and an MRI will take 45-60 minutes, leaving us little time to treat him. Look at CT scan and PET scan in the - EMR to se if you can find a better test. Return to the ER

  21. EMR & Tell Me More Button Scene A: Act 5 • MRI • What types of images it creates • When the test is best utilized • CT • What types of images it creates • When the test is best utilized • PET scan • What types of images it creates • When the test is best utilized Back to ER Scene A Back to ER Scene B

  22. Congrats Dr. ________ ! • You’ve completed the first step of treatment for the patient Mr. Jones. • Your total score for this scene is 25/25 You are off to a great start! Continue using the EMR and patient history before you make any decisions regarding your patient, and the committee looking for a chief of staff might just take a second look at your nomination! • Remember…Your instructor may want you to print this page. Editor’s note: This is just a sample of what this page would say! See template for other options.

  23. Hospital Stroke Module Scene B

  24. Patient History Scene B, Act 1 Help/Reference Materials: How a CT scan works Protocol Doctor Notes EMR 1. Run CT Scan jjlkjkjlkjkjkj Tell me more • Description/Actions: • Student clicks on Scan button • Patient enters CT machine • Move to Act 2 Run Ct Scan Next Act

  25. Scene B, Act 2 Help/Reference Materials: CT scan of nSAH stroke How to read a CT scan Normal brain CT Protocol Protocol Doctor Notes EMR Patient History Patient History M 1. Run CT Scan jjlkjkjlkjkjkj 2. Confirm primary diagnosis • Description/Actions: • CT results appear on computer along with diagnostic options • If student chooses SAH stroke, move to Act 3 • If student choose nSAH stroke, a window should appear showing what a CT scan of an nSAH stroke looks like Subarachnoid Hemorrhagic (SAH) stroke Non-subarchnoid Hemorrhagic (nSAH) stroke Tell me more Next Act

  26. Scene B, Act 3 Help/Reference Materials: Causes of hemorrhagic strokes and the corresponding treatments. Protocol Doctor Notes EMR Patient History 1. Run CT Scan 2. Confirm primary diagnosis jjlkjkjlkjkjkj • Actions: • Student determines probably cause of hemorrhage by reading about causes of SAH stroke in VMT. • Student chooses desired course of action. 3. Determine the cause of the bleed • What is causing this • brain hemorrhage? • Based on your research, will you… • Send the patient for neurosurgery? • Order a second diagnostic test? Tell me more Next Act

  27. Scene B, Act 4 Help/Reference Materials: Definitions/examples of MRI, PET scans and CT angiograms with their commons uses. Protocol Doctor Notes EMR Patient History 1. Run CT Scan 2. Confirm primary diagnosis jjlkjkjlkjkjkj • Actions: • Student chooses desired test to find aneurysm. • If chooses correctly, moves to Scene C 3. Determine the cause of the bleed • Secondary test options: • MRI • PET scan • CT angiogram 4. Order a second diagnostic test Tell me more Last Screen

  28. Dr. _______’s Notes • Ordered CT Scan • Faster • Can find bleed in brain • Less expensive Return to ER

  29. Hospital Stroke Module Introduction Prepared by Elisa Palmer & Darci Harland

  30. How a CT Scan Works EMR & Tell Me More ButtonScene B: Act 1 Return to ER

  31. Dr. _______’s Notes • Ordered CT Scan: faster, can find bleed in brain, less expensive • Subarachnoid hemorrhagic (SAH) stroke diagnosed Return to ER Bleeding

  32. EMR & Tell Me More ButtonScene B: Act 2 • How to read a CT scan • Normal brain CT • Descriptions of nSAH and SAH strokes • CT scan of nSAH stroke • CT scan of SAH stroke Back to ER

  33. Correct! The bright white areas indicate a bleed in the subarachnoid space. Great job Dr _______! Proceed! Return to ER Feedback example screen SAH stroke Bleeding

  34. CT scan of nSAH stroke Does your patient’s CT scan match this one? Try again! Your patient’s CT scan Return to ER Feedback example screen nSAH Stroke

  35. EMR & Tell Me More ButtonScene B: Act 3 • Causes of SAH hemorrhagic strokes and their treatments Back to ER

  36. Feedback example screen Neurosurgery for Mr. Jones? • Sorry, Mr. Jones’s SAH stroke if probably due to an aneurysm since there is no recent trauma in his medical history. Therefore, surgery is not a good choice for him. Try again! Return to the ER

  37. Feedback example screen A second test for Mr. Jones? • Correct! Mr. Jones’s SAH stroke if probably due to an aneurysm since there is no recent trauma in his medical history. • Now, you must determine the best test for to find Mr. Jones’s aneurysm. Hurry, the clock is ticking! Return to the ER

  38. Dr. _____’s Notes – Act 3 • SAH stroke is probably due to an aneurysm since there is no trauma in Mr. Jones’ recent patient history Back to ER Act 3

  39. Feedback example screen CT Angiogram for Mr. Jones? • Correct! A CT Angiogram will allow you to find the location of the suspected angiogram. Proceed to the CT Angiogram room! Last Screen

  40. Feedback example screen An MRI for Mr. Jones? • This patient’s symptoms started over an hour ago and an MRI will take 45-60 minutes. This may not leave you enough time for treatment. Try again!

  41. Feedback example screen A PET scan for Mr. Jones? • PET scans are normally used to show brain functioning, not cardiovascular anatomy. Try again!

  42. Dr. ________’s Notes • CT angiogram ordered in order to determine the location of the aneurysm. MRI rejected due to time issues and PET scan rejected because it would show brain functioning, not brain anatomy.

  43. Congrats Dr. ________ ! • You’ve completed the second step of treatment for the patient Mr. Jones. • Your total score for this scene is 15/15: You are off to a great start! Continue using the EMR and patient history before you make any decisions regarding your patient, and the committee looking for a chief of staff might just take a second look at your nomination! • Remember…Your instructor may want you to print this page. Editor’s note: This is just a sample of what this page would say! See template for other options.

  44. Hospital Stroke Module Scene C

  45. Scene C, Act 1 EMR: Description of how and why CT Angiograms are done. Protocol Doctor Notes EMR Patient History 1. Perform CT angiogram jjlkjkjlkjkjkj Description/Actions: Student clicks on “Run CT Angiogram” and video pops up, showing a patient having a CT angiogram scan. Move to Act 2. Tell me more • Run CT Angiogram Next Act

  46. Scene C Act 2 Electronic Medical Record: Brain blood vessel anatomy Information about clipping aneurysms Information about coiling aneurysms Protocol Protocol Doctor Notes EMR Patient History Patient History M 1. Perform CT angiogram jjlkjkjlkjkjkj • 2. Determine course • of treatment Description/Actions: CT angiogram results show that the patient has an aneurysm in the anterior communicating artery. Student must choose to either clip or coil the artery. Choose a course of treatment: Clip the aneurysm Coil the aneurysm Tell me more Next Act

  47. Scene C, Act 3 Electronic Medical Record: Video of emoblization (coiling) process. Protocol Doctor Notes EMR Patient History 1. Perform CT angiogram • 2. Determine course • of treatment jjlkjkjlkjkjkj Description/Actions: A. Student clicks on “coil the aneurysm”. B. Coiling procedure video or simulation is shown. Insert a coil into the aneurysm. 3. Perform embolization (coiling) on the aneurysm. Tell me more Next Act

  48. Scene C, Act 4 EMR: HHH therapy Vasospasms (causes and treatments) Protocol Doctor Notes EMR Patient History 1. Perform CT angiogram • 2. Determine course • of treatment jjlkjkjlkjkjkj Student clicks on “Send patient to ICU” 3. Perform embolization (coiling) on the aneurysm. Coiling of aneurysm was successful. Send patient to ICU with orders for HHHtherapy and vasospasm monitoring 4. Send patient to ICU Tell me more Last Screen

  49. EMR & Tell Me More ButtonScene C: Act 1 • Description of how/why CT Angiograms are performed. Return to ER

  50. Dr. _______’s Notes • CT Angiogram shows aneurysm in the anterior communicating artery • Aneurysm in Anterior Communicating Artery • Have decided to coil/embolyze the aneurysm due to the patient’s age and lack of invasiveness of this procedure. Return to ER

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