Hospital Stroke Module

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, MRIs, 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, youll need to do a bit
research before submitting a response.
2
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 patients
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
EMR
Doctor Notes
EMR
Doctor Notes
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 youve 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
Scene A
Act 1
Doctor Notes
1. Check patient vitals, symptoms and history.
(Hint Click patient history tab above.)

1. Participant clicks on Patient history tab
2. History is given
3. Once theyve 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
Scene A
Act 2
Doctor Notes
EMR
Click all that apply!
1. Check patient vitals, symptoms and history.

1. Participant will be reviewing patient history,
   and filling in radio buttons.
2. All should be selected except inactive. Feedback
   should be individualized see details in
   template.
3. 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
Scene A
Act 3
Description of NIH Stroke Scale Scores
Doctor Notes
EMR

• No, dont give treatment patient will recover
  without intervention.
• Yes, give treatment.
• No, dont give treatment patient is too severe
  for treatment.

1. Check patient vitals, symptoms and history.

1. 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
2. Correct answer Yes. Feedback details are in
   the template.
3. 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
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.
Feedback example screen

• Sorry, Be sure to read in the EMR, how to
  decipher the NIH Stroke Scale score.
• Return to
  the ER

10
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.
Feedback example screen

• 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
Scene A
Act 4
Descriptions of Ischemic and Hemorrhagic strokes
Doctor Notes
EMR
1. Check patient vitals, symptoms and history.

1. Participant uses EMR Tell me more button to
   learn about the differences between the 2 types
   of strokes.
2. Correct answer is Hemorrhagic. Feedback details
   in the template.
3. 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
Determine what type of stroke the patient had.
Feedback example screen

• Incorrect Compare the stroke symptoms of
  Ischemic and Hemorrhagic stroke in the EMR.
• Return to
  the ER

14
Determine what type of stroke the patient had.
Feedback example screen

• 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
Dr. ________s Notes
Editors Note The notes should not be added all
at once, but only after participants reach the
correct responses.
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
Scene A
Act 5
Descriptions of the three types of diagnostic
tests.
Doctor Notes
EMR
1. Check patient vitals, symptoms and history.

1. Participants will use the EMR or Tell me more
   button to learn about the different tests.
2. Correct answer is CT scan Feedback details in
   template.
3. 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
What test should be done to confirm your
diagnosis?
Feedback example screen

• 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
What test should be done to confirm your
diagnosis?
Feedback example screen

• 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
What test should be done to confirm your
diagnosis?
Feedback example screen

• 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. ________ !

• Youve 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!
• RememberYour instructor may want you to print
  this page.

Editors note This is just a sample of what this
page would say! See template for other options.
23
Hospital Stroke Module

• Scene B

24
Scene B, Act 1
Help/Reference Materials How a CT scan works
EMR
Protocol
Doctor Notes
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
EMR
Patient History
Doctor Notes
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
EMR
Doctor Notes
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
EMR
Doctor Notes
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
SAH stroke
Feedback example screen
Bleeding

• Correct! The bright white areas indicate a bleed
  in the subarachnoid space. Great job Dr _______!
  Proceed!
• Return to ER

34
nSAH Stroke
Feedback example screen

• CT scan of nSAH stroke
• Does your patients CT scan match this one? Try
  again!

• Your patients CT scan
• Return to ER

35
EMR Tell Me More ButtonScene B Act 3

• Causes of SAH hemorrhagic strokes and their
  treatments

Back to ER
36
Neurosurgery for Mr. Jones?
Feedback example screen

• Sorry, Mr. Joness 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
A second test for Mr. Jones?
Feedback example screen

• Correct! Mr. Joness 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. Joness 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
CT Angiogram for Mr. Jones?
Feedback example screen

• Correct! A CT Angiogram will allow you to find
  the location of the suspected angiogram. Proceed
  to the CT Angiogram room!

Last Screen
40
An MRI for Mr. Jones?
Feedback example screen

• This patients 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
A PET scan for Mr. Jones?
Feedback example screen

• 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. ________ !

• Youve 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!
• RememberYour instructor may want you to print
  this page.

Editors 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
EMR
Doctor Notes
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
EMR
Patient History
Doctor Notes
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
EMR
Doctor Notes
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
EMR
Doctor Notes
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 HHH therapy 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 patients age and lack of invasiveness of
  this procedure.
• Return to ER

51
EMR Tell Me More ButtonScene C Act 2

• Brain Blood Vessel Anatomy
• Information about Clipping Aneurysms
• Information about Coiling Aneurysms
• Return
  to ER

52
Clipping Aneurysms
EMR Tell Me More ButtonScene C Act 2

• Info on Coiling
• 
  Return to ER

53
Coiling Aneurysms
EMR Tell Me More ButtonScene B Act 2

• 
  Return to ER

54
Coiling Aneurysms
EMR Tell Me More ButtonScene B Act 3

• Insert a coil into the aneurysm. (animation)
• 
  Return to ER

55
Dr. _____s Notes

• Aneurysm successfully coiled.
• Sent patient to ICU for recovery. Ordered HHH
  therapy and monitoring for vasospasms.

56
Congratulations!

• You have successfully treated Mr. Jones within
  the necessary 3 hour time window! If you have
  scored a ___ or higher, you are still in the
  running to become Chief of Staff great job! If
  you have scored lower than a ___, perhaps the
  next stroke patient to come through the doors of
  St. Normal Hospital will have better results.
  Also, please realize that Mr. Jones journey is
  not over. He will have a 10-14 day stay in the
  ICU (where the rate of mortality from strokes is
  very high 2-12 days following the initial stroke)
  and then undergo physical therapy.

57
EMR Tell Me More ButtonScene C Act 4

• HHH Therapy
• Vasospasms

Back to ER
58
Clip the Aneurysm
Feedback example screen

• This procedure is highly invasive and should only
  be done when the aneurysm is located close to the
  surface of the brain and on younger patients.
  Please think carefully before proceeding with
  this procedure on this patient.
• Return to Patient

59
Coil the Aneurysm
Feedback example screen

• Correct! This procedure is much less invasive and
  a better choice for this patient. Go forward with
  your treatment of this patient.
• Return to
  patient