insitu sim, a big problem

Simulation report 1/2/24


In situ sim ED JHC


Hi everyone,

Thank you so much for participating and helping in last Thursdays in situ sim. I hope we all enjoyed the scenario. In order to share our learning goals, I have formulated a sim report.


Our case:

The Emergency bell went off in D-Pod. A 42 year old morbidly obese male had just been brought in with fevers and a cough.

The Nurse who conducted the initial assessment felt he had acutely deteriorated.

He looked clammy, pale and was agitated.

His initial vital signs showed that he was significantly hypoxic and shocked. Respiratory Sepsis was the most likely differential diagnosis.


This is representing one of the very challenging situations in Emergency Medicine due to following combination of pathologies and circumstances.


  1. Management of morbidly obese patient

1. reduced reserve due to body habitus, so deterioration in any physiology must be anticipated

2. problems arising from body habitus, such as

  • difficult iv access, io might not be long enough, cvc difficult due to big neck and

large abdomen

  • difficult airway and breathing management  NIV might not fit
  • BMV difficult (three hand technique, Peep valve use)
  • manage always a difficult airway
  • CPR difficult as chest compressions might be insufficient and LUKAS might not fit
  • Many more issues


  1. Severely unwell patient in first place

  2. Resuscitation in suboptimal environment

  • managed in Dpod not in Resus


The main learning goals of this scenario were


  1. Anticipation of possible deterioration early due to body habitus and underlying pathophysiology, underestimation of pathophysiology due to inacurate vital signs
  • call for help and extra hands (you are likely to need many many)
  • area: resources have to come to patient
  • this patient was too unwell for transfer to the Resus area
  • infectious risks with airway manipulation, Dpod really good place to be


  1. Resuscitation before intervention
  • Simple things first: sit the patient up and supply oxygen in stepwise approach (non rebreather to NIV)
  • C-A-B-C approach,  

Early management of shock  fluids and early vasopressors

 consideration of art line for accurate BP

 consideration of Cardioversion electrically

  1. Induction and intubation unavoidable in this patient as patient remained hypoxic and agitated
  • Less is more

         small doses of drugs, resuscitate as optimal as possible

adrenaline infusion and push doses on hand

  • detailed preparation and communication required

Patient: ramped and resuscitated, no apnoea time

Equipment: D-blade with introducer available in airway trolley

Video laryngoscopy

Operator: anaesthetics in ideal world or most senior operator in department

  • very risky scenario as patient at high risk to arrest

Be prepared for arrest, designated person on pulse

Have resuscitation drugs readily present

Thank you reading over this and I hope we could all refresh our memory about management of the unwell obese patient. There is endless more to talk about.

I will attach this podcast, its lengthy but worthwhile the listen.


Episode 69 Obesity Emergency Management


Chat soon,


Irene Pelletier