Clinical Decision Making: Sickle Cell Crisis with Acute Chest Syndrome
Correspondence should be addressed to Ryan Adkins, DO at ryan.adkins@commonspirit.org
DOI: https://doi.org/10.5070/M5.53173
ABSTRACT:
Audience: This clinical decision-making case (CDM) is intended for emergency medicine residents (interns, juniors, seniors).
Introduction: Acute chest syndrome (ACS) is a life-threatening complication of sickle cell disease and can be a common cause of ICU admission in these patients. Emergency physicians must rapidly identify, diagnose, and treat ACS to prevent deterioration. Acute chest syndrome is the most prevalent pulmonary disorder in individuals with sickle cell.1,2Approximately 50% of patients with sickle cell disease will experience more than one episode of acute chest syndrome, with 78% of episodes secondary to vaso-occlusive pain episodes in adults. It is the most common cause of death in individuals with sickle cell, accounting for almost 25% of all deaths.3
Educational Objectives: By the end of this clinical decision-making case, learners will be able to: 1) demonstrate familiarity with a case, 2) identify focused historical and physical exam findings in ACS, 3) develop a differential diagnosis for chest pain in a sickle cell patient, 4) select and interpret appropriate diagnostic studies, 5) initiate ED management including oxygen, antibiotics, and pain control, 6) recognize when to consult hematology and consider transfusion, 7) appropriately disposition the patient and communicate a transition of care, and 8) explain the pathophysiology of ACS.
Educational Methods: The development of this case was grounded in Kolb’s experimental learning theory.4 This process includes four stages: experience, reflection, conceptualization, and experimentation to solidify learning of skills and concepts. This case was delivered in three phases to encompass all stages of Kolb’s learning theory: flipped classroom instructional video simulated practice and role play and formal assessment (the scoring checklist). This case uses a structured oral board simulation based on American Board of Emergency Medicine’s (ABEM) Clinical Decision-Making format (CDM).5 First, the residents were asked to watch a video from the ABEM website on how to perform the CDM model. Immediately afterwards, they were asked to reflect on whether they had had previous experience with this model of teaching and to fill out the survey. Finally, on a simulation didactic day, residents were randomized into groups of three to four. An emergency medicine attending administered the case over 15 minutes to one resident in the group, while the other group members observed over 15 minutes, with 25 minutes to debrief. Learners answer standardized prompts in a timed, non-roleplay format, enhancing diagnostic reasoning and management planning. The attending and a separate resident then scored the participant using the provided scoring. Immediately afterwards a brief debrief was held and the scores were reviewed. The method aligns with constructivist learning theory and supports deliberate practice.
Research Methods: Residents were consented and then randomly assigned a study number, and they filled out pre- and post- confidence level surveys based on their experience with the clinical decision-making format. A Likert scale was used from 1-5, 1=Not at all confident, 5 = Very confident. After completing the in-person case session, the residents were asked to fill out a post-confidence level survey. To assess whether the intervention led to statistically significant changes in confidence levels, we conducted a paired t-test across the pre- /post- groups.
Results: Thirteen residents consented to and participated in the study by completing both the pre-and post-confidence level survey. Eight of the residents were PGY 1, and five were PGY 2. Between both groups, the confidence level improved overall from 1.86 pre- to 2.92 post (P=0.005). PGY 1 residents had a lower confidence level, starting out at an average of 1.5 with improvement to 2.63 (P=0.026), compared to PGY 2’s who started out at 2.4 and improved to 3.4 (p=0.089). The PGY 2 improvement was not statistically significant.
Discussion: The structured format allowed for targeted feedback and consistent assessment. Residents appreciated the immediate feedback and felt more confident in their preparation with the oral boards clinical decision-making format. Interns had the greatest improvement in confidence levels when compared between residency classes. This could represent PGY 2’s increased clinical experience. This format was done in the first months of residency as well, and it would be interesting to see if there was improvement from the beginning of the year to the end in the intern class just from patient exposure. Our program does not currently have PGY 3’s but repeating this study in the future would be beneficial to compare and see if the largest gains are in the intern and junior residents with less clinical experience.
Topics: Acute chest syndrome, sickle cell disease, hypoxia, chest pain, exchange transfusion, incentive spirometry, ICU admission, ABEM oral boards, antibiotic management, emergency medicine simulation.
