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SUMMER 2017
SUMMER 2017
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Returning home with his girlfriend from a trip to Cambodia, a
young man arrives in the ED in heart and respiratory distress
after vomiting continuously for hours. Within minutes, he
begins to have seizures.
Over the next 20 minutes, the medical team requests a
battery of tests, consults with supporting clinicians, dispenses
medication, and extrapolates pertinent information from a
highly agitated patient and his less than forthcoming girlfriend.
(It was later discovered that the patient had ingested a large
amount of cocaine.) This is all done so the team of emergency
medicine doctors, fighting against the clock, can quickly
piece together the clues in hopes of determining the patient’s
diagnosis – and saving his life.
Just another day in the life of a busy city emergency room – or
so it would seem. Only this time, it’s the Bronx Sim Wars, a
battle between emergency medicine resident teams from three
Bronx hospitals, SBH, Jacobi/Montefiore, and Lincoln.
The competition was created as a collaborative effort between
sim leaders at Jacobi and SBH, and conceived as a fun and
educational exercise for residents, says Dr. Mina Attaalla, SBH’s
director of simulation education and informatics.
According to Dr. Marianne Haughey, director of the emergency
medicine residency program at SBH, "I am thrilled to have this
opportunity to bring the three emergency medicine residencies
from our borough together to jointly enhance education. The
good natured competition allows for a spirit of excitement as we
work to improve care for our Bronx patient population. I think
this reflects the unity of the baseline motivation of emergency
medicine – the goal to give our patients the best possible care
despite whatever challenges exist. As we work together we only
get smarter and better at what matters – providing world class
emergency care."
Held in the auditorium at SBH before a packed audience, the
event was at times both dramatic and comedic. Each five-
member team worked on a patient who transformed from an
actor to a state-of-the-art mannequin. “Hal” is an advanced
multipurpose patient simulator that features physical and
physiological features capable of simulating lifelike cases in
an ED setting. This includes airway and lung compliance that
allows for ventilation and sensors for drug recognition and real
life monitoring.
A panel of judges, comprised of emergency medicine physicians
who serve as medical directors of simulation labs at New Jersey
Medical School, St. John’s Riverside Hospital and Elmhurst
Medical Center, scored the three teams on their clinical actions,
teamwork and communications.
The SBH team, comprised of Drs. Natalie Hubbard, Christina
Hajicharalambous, Jimmy Truong, Maisah Shaikh and Yash
Chavda, emerged victorious. As a result, the Bronx Sim Wars
cup will reside at SBH for the time being, or at least until the
next winner is crowned.
RESIDENT NEWS
First Bronx SimWars Offers Educational Opportunity
For EmergencyMedicine Residents
By Steven Clark
SBH ETHICS
Mr. B. is a 58-year-old man with COPD who
presents to the ER with increasing swelling and pain
in his legs associated with shortness of breath. In
the emergency room he is noted to have increasing
shortness of breath and restlessness. Treatments for
COPD and CHF are administered, but his respiratory
status deteriorates rapidly. The patient, who is fully
alert and oriented, tells the doctors that he is DNR
and does not want to be on a machine. He becomes
increasingly combative and hostile requiring physical
restraints. He is told he will die without intubation;
he does not change his advanced directive. His sister,
contacted via telephone, states that she does not know
her brother’s end of life wishes, but requests that
everything be done to keep him alive. He is sedated,
intubated and sent to the ICU.
Later that shift, Mrs. G., a 98-year-old woman with profound
dementia, severe cachexia, and frailty presents via ambulance
from a nursing home. She is laboring to breathe, is frail and
cachectic. Records from the nursing home reflect that she is bed
bound, nonverbal and fed via PEG tube. A chest x-ray shows
a large lung mass with diffuse metastatic illness throughout
all lung fields. The nursing home transfer form identifies the
patient as full code and lists a health care proxy; however, the
nursing home cannot be reached via telephone. The ER physician
debates not intubating the patient given her dismal baseline
functional status and newly diagnosed metastatic lung cancer.
Discussion:
Perhaps no conversation is more difficult than the discussion
regarding end-of-life wishes. Patients and families are often
reluctant to discuss death and are often unaware of the need
to appoint a health care proxy. Although recent changes in
Medicare reimbursement now allow physicians to bill for end-of-
life discussions, doctors are challenged finding the time and lack
the ability to facilitate these difficult conversations. In the Bronx,
where social support and family structure is often fractured, it is
not uncommon to find a patient who not only has no advanced
directive, but has no family or friends who could serve as a proxy
or surrogate decision maker. Unfortunately, many end-of-life
decisions are made in times of crisis where emotions are high,
time is short and discussion is not possible.
These cases illustrate the conflicts between patients’ rights –
upholding patient autonomy, right to self-determination and
the need to preserve life – and doctors’ decisions – the role of
paternalism and the directive to first do no harm.
Taking a Closer Look at End-of-Life Wishes
By Steven Reichert, MD, Division Director, Palliative Care
