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. Tell me more EMR Doctor Notes EMR Patient History Doctor Notes Protocol The protocol: This tab lets you know what actions you need to take. Consider this your directions on what to do next. Questions that you must respond to will be found here. 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. 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 Tell me more 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. Images from exams will be shown here. 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. 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. Patient History: Gives patient history and test results.. Click Here to Begin! Click this “Go” button once you’ve chosen a response to the question.

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

8. Doctor Notes EMR Patient History Protocol Doctor Notes Descriptions & Actions Help & Reference Materials Scene A 1. Check patient vitals, symptoms and history. Act 3 2. Determine which high risk factors the patient has for stroke. 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) a.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 b.Correct answer: “Yes.” Feedback details are in the template. c.Once participant gets the correct answer & feedback automatically go to next act. No, don’t give treatment: patient will recover without intervention. Yes, give treatment. No, don’t give treatment: patient is too severe for treatment. Tell me more Description of NIH Stroke Scale Scores The NIH Stroke Scale Score was 17. What do you think Dr. (participant’s last name)? Should we treat this patient or not? The ER doctor pipes in… Close window 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. Sorry, Be sure to read in the EMR, how to decipher the NIH Stroke Scale score. Return to the ER Feedback example screen

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. 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 Feedback example screen

11. EMR & Tell Me More Button 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 Scene A: Act 3 Back to ER

12. Doctor Notes EMR Patient History Protocol Doctor Notes Descriptions & Actions Help & Reference Materials Scene A Act 4 1. Check patient vitals, symptoms and history. 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. Ischemic Hemorrhagic Tell me more a.Participant uses EMR & Tell me more button to learn about the differences between the 2 types of strokes. b.Correct answer is Hemorrhagic. Feedback details in the template. c.Once participant gets the correct answer & feedback automatically go to next act. Next Act Descriptions of Ischemic and Hemorrhagic strokes

13. 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 Feedback example screen

14. 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 Feedback example screen

15. EMR & Tell Me More Button 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 Scene A: Act 4 Back to ER

16. Dr. ________’s Notes #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. For Scene A Back to ER Editor’s Note: The notes should not be added all at once, but only after participants reach the correct responses.

17. Doctor Notes EMR Patient History Protocol Doctor Notes Descriptions & Actions Help & Reference Materials Scene A Act 5 1. Check patient vitals, symptoms and history. 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. Tell me more a.Participants will use the EMR or Tell me more button to learn about the different tests. b.Correct answer is CT scan: Feedback details in template. c.Once participant gets the correct answer & feedback go to final scene screen. 5. What test should be done to confirm your diagnosis? MRI PET scan CT scan Descriptions of the three types of diagnostic tests. Last screen

18. 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 Feedback example screen

19. 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 Feedback example screen

20. 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 Feedback example screen

21. EMR & Tell Me More Button 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 Scene A: Act 5 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. jjlkjkjlkjk jkj Run Ct Scan EMR Protocol Doctor Notes 1. Run CT Scan Description/Actions: a.Student clicks on Scan button b.Patient enters CT machine c.Move to Act 2 Help/Reference Materials: How a CT scan works Scene B, Act 1 Patient History Next Act Tell me more

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

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

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

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. 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 EMR & Tell Me More Button Scene B: Act 2 Back to ER

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

34. nSAH Stroke 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

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

36. 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 Feedback example screen

37. 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 Feedback example screen

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

40. 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!Try again! Feedback example screen

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

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

46. jjlkjkjlkjk jkj M Choose a course of treatment: Clip the aneurysm Coil the aneurysm 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. Electronic Medical Record: Brain blood vessel anatomy Information about clipping aneurysms Information about coiling aneurysms Scene C Act 2 Protocol EMR Patient History Protocol Doctor Notes Patient History Tell me more 1. Perform CT angiogram 2. Determine course of treatment Next Act

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

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

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

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

51. Brain Blood Vessel Anatomy Information about Clipping AneurysmsClipping Aneurysms Information about Coiling AneurysmsCoiling Aneurysms Return to ER EMR & Tell Me More Button Scene C: Act 2

52. Clipping Aneurysms … Info on CoilingInfo on Coiling Return to ER EMR & Tell Me More Button Scene C: Act 2

53. Coiling Aneurysms Return to ER EMR & Tell Me More Button Scene B: Act 2

54. Coiling Aneurysms Insert a coil into the aneurysm. (animation)Insert a coil into the aneurysm. Return to ER EMR & Tell Me More Button Scene B: Act 3

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. HHH Therapy Vasospasms EMR & Tell Me More Button Scene C: Act 4 Back to ER

58. Clip the Aneurysm 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 Feedback example screen

59. Coil the Aneurysm 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 Feedback example screen