Managing Emergencies in Primary Care

7/29/2019 Managing Emergencies in Primary Care

1/47

Managing Emergencies in Primary Care

A Resource pack for running simulations

Dr. Eric Britton MD MPH MRCGP

Programme Director ST

London Deanery


2/47

2 Introduction:

Primary Care Emergencies London Deanery 2010

Introduction:

The purpose of this resource pack is to provide Programme Directors and Trainers with a means ofpreparing GP Specialist Trainees ^d to deal with emergency situations in the primary care setting.

The London Deanery has recognised that acute emergencies are rare in primary care and it is

possible that a ST will not have the opportunity to contemporaneously experience an emergency in

which to learn and practice skills during the GP portion of their training; therefore not fulfilling a

major part of the RCGP Curriculum.

^^d experience in managing acute emergencies during the

secondary care portion of their training, but there are several reasons why it is felt that specific

training for the primary care setting is essential. With the expansion of training in GP from 12 to 18

^dexperience acute emergencies due to the lower prevalence in primary as opposed to secondary care.

Moreover, with the move to create secondary care posts located predominantly in outpatient

departments or in future poly-clinic type facilities, the opportunity for emergency care experience

will be decrease even more over the full scope of GP training.

However, the most important reason for the creation of this resource pack is the problem of

contextd^d for acute

emergencies, e.g. ALS, PALS etc., is in the bosom of the hospital network; a network where a team of

similarly trained and practiced professionals are present with resources, e.g. defibrillators, venflons,

emergency medications etc., close to hand. Moreover, the teams get to practice with someregularity these skills on real cases.

In contrast in primary care, although the materials are usually available and maintained just in case a

situation should arise, these skills are rarely used. Moreover, the supportive practitioners (nurses,

receptionist and fellow clinicians), although receiving yearly training; may wait years before they get

to practice their skills on a real case. Furthermore, the ST, being transplanted from the relatively

standardized and familiar context of the hospital or outpatient department to a new and much more

variable primary care setting, will be disoriented and relatively isolated if confronted with a patient

having a life threatening event. Finally, many ST

emergency care will never have taken the responsibility for directing the care, being the leadclinician during the emergency.

Although knowing what to do intellectually, practicing their skills in a non-hospital setting is very

different on a qualitative level. Assumptions shared by a team of hospital practitioners who deal

with emergencies on a daily basis are not present. The ST will need to be clearer in what they are

asking for, instructing inexperienced colleagues in moments of heightened emotional tension clearly

and exactly. In addition they may need to improvise, not following the standard algorithms, due to a

lack of materials available. The scenarios in this resource pack have been structured to provide

realistic situations in primary care. They have been trialled with a 2 focus groups ^d

that it was not the knowledge that was difficult but the setting and feeling of being more alone andunsupported that was important in the role plays.


3/47

3 Introduction:


^d

invaluable experience. In addition, feedback from programme directors, actors acting as role players

and physicians who are experienced in both primary care and emergency medicine were canvassed

to ensure that these scenarios were realistic and pertinent to the objectives of the exercise.

It is hoped that this resource pack will provide a means of providing experience of emergencies in

the primary care context and thus provide more confidence to allow better provision of emergency

care ^d over their GP careers. These scenarios do not replace basic training in BLS, ALS, or PALS.


4/47

4 Objectives


Objectives

1. To provide experience of common Primary Care Emergencies that although common are

^d

2. dW suggested materials to run a seminar addressing Primary Care

Emergencies in total or in part.

3. To provide a flexible series of case scenarios so that they can be re-used in the same session

or repeated within a 3 year cycle.

4. To provide a list of available or easily obtainable resources for the staging of a seminar.

5. Scenarios are to allow for the ST to

a. Use knowledge already known

b. Practice clinical skills necessary to treat the patient

c. Practice decision making, negotiation, and use of services in a safe but realistic

situation.

d. Refine leadership skills in an emergency situation

e. Reflect on the communication skill required when dealing with patients and

colleagues in these situations.

6. BLS with AED training, PLS, & ALS should be addressed under a different venue but its

principles are assumed to be used and understood in these scenarios


5/47

5 Educational Methods and Materials:


Educational Methods and Materials:

Use of Cases:

The cases in this resource pack can be used in several ways. In the first use, the text can be used as a

script for a guided role play where an actor or role player can follow the script and a tutor (PD or

Trainer) can use the questions to guide a candidate through the scenario. The tutor should make

available equipment to be used to practice skills appropriate to the scenario. These could include a

resuscitation bag with placebo medication, an ambi-bag, oxygen tubing, or a CPR dummy to practice

chest compressions etc. Various props can be improvised if they are not available. The tutor should

use the text to guide the subject but if possible they should allow the role play to develop as

naturally as possible.

In the role playing situation, the scenarios are very much like an improvisational play where the ST

and the role players are actors and the tutor is the director, much along the lines of the Television

Programme, Whose line is it anyway?The tutor may wish to manipulate the situation to vary the

announcing the sudden death of the patient and substituting a resuscitation dummy for the ST to

work with, or asking for gui

d

good working knowledge of emergency practice and the scenarios to allow ease of execution.

The second use would be more as a written or oral OSCE where the subject could be asked to

demonstrate a skill on a dummy or simply write out their reactions to the text as part of a station in

a larger OSCE.

A third use could be used as a case presentation with review of evidence in a seminar format.

Case Structure:

Each case has a format of a basic case introduction with a core history that can then diverge to two

to three different stems which lead to different outcomes. These stems have assumed different

underlying diagnoses, but it is not necessarily important that the ST make the correct diagnosis but

simply respond appropriately as the first responder to the emergency.

The varied stems are present so that the case can be rerun with the same role players to allow for

variety of experience and to create more scope for re-use over a 3 year training cycle of a specialty

training programme.

In addition to the master case which provides the basic script for the tutor to follow there are

directions for the role players. It is not necessary for the role players to understand what is

happening to them, and to create a more realistic situation it may be good not to inform them.

Planning a role playing session:

Before using a role playing session it is very important to sit down with the role players, either actors

or volunteering Sd the tutor would like to unfold during the course of events. It is

advisable that the role players be provided with the case scenarios in advance so that they can

prepare their characters and their actions. The use of actors who have been trained in medical role

play with experience in providing feedback is highly advised. In the development of these scenariosactors from the Sympatico Agency proved invaluable in providing realism to the situation as well as

providing feedback on the ST -verbal.


6/47

6 Proposed Materials:


Proposed Materials:

List of Equipment for use with these cases:

x

^ddW x CPR Dummies, Adult and Baby

x Oxygen Tubing

x Resuscitation/Emergency Bag

x Doctors Bag

x Nebulizer (or simply the mask and tubing)

x Stretcher or Examination Couch

x Venflons Syringes etc.

x Urinalysis Sticks

x Glucometer

x Urine Pregnancy Tests

x Picture or video of various conditions and findings: e.g. Spotting the Sick Child, Anaphylaxis.


7/47

7 Notes for Tutors


Notes for Tutors

Due to the constraints of written text, the cases are presented in a linear fashion but the actual role

/ tutor

understand the case and make allowances to jump from one part of the script to the other. They

may choose to alter the scenarios to meet specific situations or exigencies of the training day. The

important goal of these scenarios is to keep the scenario realistic and to keep a sense of urgency to

the situation. During the development of the scenarios, ^d

do was not the problem, but the context of being away from the hospital team was the most

important and difficult with which to deal. Moreover^d

care training, they rarely had the opportunity to take the final decision, often deferring to a senior

giving medication, or stopping resuscitation)

It is possible to run the cases without a separate role player, where the tutor plays various roles as

required and the patient is a resuscitation dummy on which skills can be practiced. Whether the

scenar

Z

will be rusty and may have never experienced a similar situation. In these cases it is very important

s are forced to be very clear in their directions, take

control of the situation, and demonstrate confidence and leadership in a rare situation. Therefore,

the tutor may need to prompt the candidate to restate the request/command, in order to be

understood. Moreover, it may be good to run a scenario, de-brief, and re-run the scenario allowing

the candidate the opportunity to practice the areas where they could improve.

Finally, it is very important to place the candidates in the uncomfortable position of not having usual

or functioning equipment available. Although practices are meant to have all appropriate equipment

available and maintained, realistically, due to the low incidence of these situations, even functioning

equipment will be difficult to locate in the heat of a stressful situation. Moreover, it is important to

W^d

situation when the role player in a consultation scenario suddenly becomes deathly ill, collapsing in

^d .


8/47

8 General Questions for Discussion:


General Questions f or Discussion:

These questions can be posed after running the scenarios to try to draw out certain themes and

basic knowledge and skills that cross all contexts?

1. What is the difference between dealing with life threatening situations in the

community and in hospital?

a. Do you think you need different skills?

b. Do you feel that it is necessary to practice dealing with these problems in

different contexts?

c. What aspects of the context make them different from the hospital setting?

d. If you have others helping you are there any considerations you need to take

account of when dealing with your assistants?

2. In each scenario, what was the presumed diagnosis?

a. In what situations would you not follow the BLS guidance?b. Do you feel it is necessary to carry all necessary equipment with you at all

times?

c. Is it important to know what the diagnosis is?

3. When do you decide to stop resuscitation?

a. What factors cause you to take such a decision?

b. Who should make the decision?

c. What role does the family take?

4. When an emergency is taking place what other things should you be considering in the

back of your mind while you are dealing with the major event?a. List a few of the things you should be concerned about.

b. Who should you recruit to help you with these other considerations?

5. After the emergency is over what should your next steps be?


9/47

9 Case 1 Chest Pain:


Case 1 Chest Pain:

Diseases Covered:

x

Acute MI (Stem 1)

x Dissecting Thoracic Aneurysm (Stem 2)

Suggested Materials Needed:

x Actor/Role Player

x Resuscitation Dummy

x Oxygen Tubing

x AED

x Ambi Bag

x Doctors Bag/Emergency Pack

Case:

55 year old married man with type 2 diabetes for 10 years, hypertension, former smoker quit a year

ago(20 pack years), on all appropriate medication but is not compliant with diet or medications. He

has recently been given the diagnosis of prostate cancer and he is currently being staged. The

patient has coming in to the surgery for a routine diabetic check with the nurse. The nurse has called

you to see him in her room as he does not look well.

As you enter the room the patient appears grey and breathless and he his holding his left arm to his

chest. He lies back on the trolley with his eyes closed; he is conscious but appears to be in a lot of

discomfort. He is pale and sweaty.

Question: At this point what is your differential diagnosis?

[MI/ACS, PE, Pneumonia, Dissecting TA, Sepsis]

Question: What steps would you take at this point?

[Assess ABCD, Oxygen, Vital Signs, and History in that order]


10/47

10 Case 1 Stem 1:


Case 1 Stem 1:

Patient is awake, breathing and conversant but in obvious pain.

He tells you that he has been feeling well until this morning when he awoke with some chest pain

, it came back and is

worse.

Vitals taken by the nurse are: T 36.8 Pulse 110 BP 180/110 RR 20

Question: What do you what to know now?

[History: Nature of the Pain: Pressure radiating to Left Arm

Has it happened before? : NO, Feeling sick]

[Answer: Examination: Patient is awake, but sweaty and pale, his extremities are

cold, his cardiac exam gives a rapid heartbeat with normal heart sounds, and he hasbi-basal crackles]

Question: What other actions should you be taking?

[Answer: Other Actions: Try to obtain IV Access if feasible arrangements should be

made for reception to call ambulance]

Question: Do you want to give any medication?

[Answer: SL GTN, IV/IM Morphine, oral Aspirin, Continue Oxygen]

Monitor BP Still 180/110]

You continue to monitor the patient and are waiting for the Ambulance when the patient head

slumps to the side and he becomes unresponsive.

Question: What do you need to do now?

[Answer: ABC: you stabilize the airway and he is breathing but he has a very thread

and rapid pulse. Vitals: RR 6 and shallow, radial pulse at first rapid then nonpalpable, very weak brachial pulse if can be found, BP unreadable on machine]

Question: What most likely has happened and what equipment do you want to use?

[Answer: Pt has gone into a terminal rhythm (VT/VTach/Asystole) and you need to

attach the AED to the patient if available]

Question: What do you do now?

[Answer: Defibrillate with the AED, tutor will need to tell the candidate when the

AED says the rhythm is shockable ]

Question: The patient stops breathing what do you do now?


11/47

11 Case 1 Stem 1:


[Answer: Bag mask ventilate as part of BLS]

Question: Do you do External Cardiac Compression?

[Answer: Yes if you think the pulse is insufficient for delivering oxygenation to thetissues]

Question: Do you call for any more help?

[Answer: Get other doctors or a nurse in practice to help with the BLS, getting access

etc.]

Question: Do you give any medications?

[Answer: Epinephrine as per BLS guidelines]

The Paramedics arrives first and takes over bag mask, 5 minutes later 2 ambulance drivers also arrive

and relieve the nurse from chest compressions.

Question: What do you tell them when they arrive?

[Candidate should give the history and diagnosis in a short succinct sentence]

They eventually get a pulse and rhythm and make arrangements for transfer to A&E.


[Answer: Has the patient come with anyone, if so need to tell them, need to

document the episode in the notes, check on the feelings of those involved, can they

return to their jobs. Take a short break before returning to seeing patients. Let

reception know what happened and how you want to manage the patients you

hile you were taking care of this patient]


12/47

12 Case 1 Stem 2:


Case 1 Stem 2:

Patient is awake, breathing and conversant but in obvious pain.

He tells you that he has been feeling well until this morning when he awoke with some chest painbut it subsided. He was ok until he

worse.

Vitals taken by the nurse are: T 36.8 Pulse 110 BP 180/110 RR 20

Question: What do you what to know now?

[History: nature of the pain is constant and radiating to back, feeling sick]

[Examination: Pale cold and clammy, in significant discomfort and grimacing in pain,

the patient becomes less responsive, mumbling and crying in pain, his cardiac exam

give a constant murmur and he has crackles on his chest, it is a difficult exam as he is

crying for you to help him]

Question: What other actions should you be taking now?

[Other Actions: Arrangements should be made for reception to call Ambulance]

Question: What Diagnosis do you tell them to tell the Ambulance Service, what else might they

want to know?

[Very ill patient with a cardiac condition, you will need a stretcher, paramedic and it

unwell]

You monitor the patient and the BP falls to 90/60; Pulse thready in the right arm but regular around

150 it is stronger in the right arm, Pt is pale and very sweaty and distressed

Question: What is your differential of the cause now?

[Dissecting Thoracic Aneurysm, Major MI with pump failure, Cardiac Tamponad]

Question: What is the condition evolving at the moment?

[Cardio-genic Shock]

The patient becomes totally unresponsive, the blood pressure machine begins to beep and the nurse

starts to fuss with it. Reception tannoy up to the room and tells you the ambulance is on the way.


[Assess ABCD, again, IV Access if possible, ECG/ attach AED]

The patient is not breathing, he is very pale and has cold extremities and there is no radial pulse. The

AED is showing Vfib.


13/47

13 Case 1 Stem 2:



[Answer BLS with AED algorithm; practice CPR, Bag Mask, using AED]

Question: Do you call for any more help?

[Get other doctors or a nurse in practice to help with the BLS, getting Access etc.]

Question: Do you give any medications?

[Answer: Epinephrine as per BLS guidelines, tutor can ask what the route would be

and what the dose would be]

The Paramedic arrives first and takes over Bag mask, 5 minutes later 2 ambulance drivers also arrive

and relieve the nurse from chest compressions. After 30 minutes you decide to stop.


[Answer: Has the patient come with anyone, if so need to tell them, if not you need

to find out his next of kin. You need to document the episode in the notes and

complete a death certificate; check on the feelings of those involved, can they

return to their jobs? Take a short break before returning to seeing patients. Let

reception know what happened and how you want to manage the patients you

eing while you were taking care of this patient, perhaps ask another

doctor to help you with your work]


14/47

14 Case 1: Notes for the Role Players:


Case 1: Notes f or the Role Players:

Patient:

You are a 55 year old person with diabetes and you have just been diagnosed with cancer of the

prostate bu You have a spouse but no children; you have

worked as a clerk at a department store for years. You have started to take better care of yourself:

you stopped smoking a year ago and you have been trying to be a better patient when it comes to

your diabetes. You have always taken all your medications and you try to eat well since being

diagnosed with diabetes but you do like cake. You came to see the diabetes nurse this morning and

although you have been feeling unwell with chest pain/pressure this morning going to your left arm

and/or to your back (that came on in the morning when you awoke but subsided) you wanted to

make sure you got to your appointment today. You came this morning in a slight rush with the plan

to go off to work. When you came up the stairs in a bit of a rush to get through the appointment, so

you could get off to work, the pain in your chest came back with a vengeance.

In Stem 1: The pain is like an elephant standing on your chest and your left arm is very painful,

hold both to your chest. The pain is very bad and you have a sense of terror/impending doom in

your soul. You will start the role play sitting on the side of the examination couch but you will

eventually lay back in a lot of pain. You are eventually going to become unconscious. Upon becoming

unconscious a resuscitation dummy will transform into you. Please just step out of the way at that

point.

In Stem 2: The pain is like tearing pain in your chest and it radiates to your back and your left armis also very painful, hold both to your chest. The pain is very bad and you have a sense of

terror/impending doom in your soul. You will start the role play sitting on the side of the

examination couch but you will eventually lay back in a lot of pain. You are eventually going to

become unconscious and die. Upon becoming unconscious a resuscitation dummy will transform

into you. Please just step out of the way at that point.

Nurse:

You are a senior practice nurse, you started out working on the wards of the local hospital but you

z

and teaching patients about how to manage their disease. You are not responsible for the checking

of emergency equipment, . You have managed never to

have to deal with an emergency since being in General Practice. You do however attend all the

training. You feel a bit out of your depth in this situation. You will respond correctly to exact

z

while to find things when asked to get them. If you are asked to ask reception to do something; only

report back if specifically asked to do so. If the receptionist has the opportunity to not understand

what is going on report this back to the doctor.

Other roles:Unless they are an arriving paramedic/ambulance driver, if others are ask to participate, please

ensure they understand that they should be more junior doctors to the doctor in charge, e.g.


15/47

15 Case 1: Notes for the Role Players:


medical students, receptionists, nurses coming to help. They should be willing to help and if they

have the skills they should offer them e.g. doing chest compressions, but they should act in a

tentative manner and await clear and explicit instructions.


16/47

16 Case 2 Collapse in Surgery:


Case 2 Collapse in Surgery:

Diseases Covered

x

Anaphylactic Shock (Stem 1)

x Severe Syncope (Stem 2)


x Actor/Role Player


x Oxygen Tubing

x Ambi Bag

x Doctors Bag/Emergency Pack

Case:

32 year old female with obesity asthma and hay fever presented to the nurse for her flu jab and

some fasting bloods. You are passing the nurses room on your way to the kitchen when you hear a

thud and a call for help. You walk into the room and see the patient on the floor and the nurse

kneeling over her.

Question: What is your initial response?

[Assess ABCD, Oxygen, Vital Signs, and Exam & History in that order]


17/47

17 Case 2 Stem 1:


Case 2 Stem 1:

[Airway is ok, and she is breathing, Pulse is 150, Blood pressure is 80/40, her

respiratory rate is around 25 and there is an audible wheeze/ stridor, she is coming

up in an urticarial rash on her chest and her lips are swelling slightly. She is conscious

and responsive but mumbling]

While you are examining the patient the nurse tells you that the patient was waiting to leave after

her injection and he was putting the details in the computer. The patient had been slightly afraid of

needles and they were chatting; she felt a little unwell and the nurse asked her not to get up until

she felt ok. The nurse went to the fridge to get the box the vaccine was in when she heard a thud

and the patient has slipped from the chair onto the floor.

Question: What is the diagnosis?

[Anaphylactic Shock]

Question: What steps do you take now?

[See Resus UK Guidelines in Appendix]

Question: In what position should the patient be placed?

[On back with someone watching the airway, with legs elevated]

Question: What drug do you wish to give first and by which method do you wish to give it?

[Epinephrine 1:1000 IM in the thigh (5 ml of a standard Emergency Ampoule)]

Question: What other medication should be given?

[Chlorphenamine (Piriton) and Hydrocortisone IM, Oxygen]

Question: What else should be happening at the same time?

[Somebody should have been asked to call for the Ambulance]

Question: What should the receptionist be told to tell the Ambulance?

[They should be specific that the patient is in Anaphylactic Shock, is semi-conscious

and that a paramedic needs to be sent]

The patient starts to cough and splutter and then wretches, and starts to vomit.

Question: What do you do?

[Place the patient in a recovery position and encourage pt to keep mouth empty.

Continue to monitor the Airway]

Question: Should you intubate the patient?


18/47

18 Case 2 Stem 1:


[No not if they are still breathing, maintain the airway if possible without intubation

especially if conscious, you can breath for the patient using a bag mask. As the

airways are probably swollen attempted intubation may complicate the problem]

The paramedic and Ambulance arrive and take over the care of the patient. The patient has stoppedwheezing but is still groggy.


[Speak to reception and see if they can give you some space to take a break with the

nurse involved, talk through what you did , look at the records and see if there was

anything that may have indicated an allergy to the vaccine, decide how you are

going to document it and who is going to contribute to a critical event analysis, set a

date for when you are going to review the evidence that you are gathering and with

whom, e.g. between you and the nurse versus at a practice meeting]


19/47

19 Case 2 Stem 2:


Case 2 Stem 2:

[Airway is ok, and she is breathing, Pulse is 40, Blood pressure is 80/40, her

respiratory rate is around 12. She is unconscious but responsive to pain with a

sternal rub, she is slightly clammy]

While you are examining the patient the nurse tells you that the patient was waiting to leave after

her injection and the nurse was putting the details in the computer. The patient had been slightly

afraid of needles, the patient felt a little unwell and the nurse asked her not to get up until she felt

ok, she then gave the jab. The nurse went to the fridge to get the box the vaccine was in when she

heard a thud and the patient has slipped from the chair onto the floor.


[Syncope]

Question: What do you do next?

[Continue to monitor pulse and blood pressure lift legs, and wait for the patient to

come around, her pulse comes up to 100 and her blood pressure is 120/60]

The patient comes around and you ask her what happened. She says that she had just been given

the jab and then the whole room went black. She feels a little sick but is otherwise ok.

Question: Do you send her to A&E?

[You should first assess if she has any injuries or sequellae. If she is well it is not

necessary to send her to A&E]


20/47

20 Case 2: Notes for the Role Player:


Case 2: Notes f or the Role Player:

Patient:

d tutor directing

appropriately and making appropriate noises for wheezing, and vomiting. If a role player is used they

will need to be good at fainting and should also make sure they are dead weight when being placed

in the recovery position and slow to arise, unsteady on feet when getting up. If not helped up

appropriately they should stumble and fall again if appropriate.

Nurse:

You are a junior, you started out working on the wards of the local hospital but you left because you

z

You have been asked to work in the immunization clinics and have had your anaphylaxis training but

you have never had to deal with a problem. You are not responsible for the checking of emergency

equipments, but you k

z his

situation. You will respond correctly to exact instructions but if you feel the instructions are unclear

z

If you are

asked to ask reception to do something; only report back if specifically asked to do so. If the

receptionist has the opportunity to not understand what is going on report this back to the doctor.

You had just given a patient her influenza injection and she was feeling a bit unwell due to being

z

put the details in the computer you heard a thud and the patient was lying on the floor. You

panicked and yelled for help as you went to the patient.

Other roles:

Unless they are an arriving paramedic/ambulance driver, if others are ask to participate, please






21/47

21 Case 3 Home Visit: Abdominal Pain


Case 3 Home Visit: Abdominal Pain

Diseases Covered:

x

Ectopic Pregnancy, Intra-abdominal haemorrhage (Stem 1)x Appendicitis with rupture (Stem 2)

Materials:

x Doctors bag with usual supplies (no venflons or blood drawing materials.)

Case:

You are in the middle of a busy Urgent Surgery and your trainer calls you and asks you to do a visit

on a 46 year old woman who has just called complaining of abdominal pain but refusing to come

down to be seen at the surgery. Your trainer says she would go herself but she has a meeting atlunch time and besides it will be good for you to do the visit after you finish the urgent surgery. You

get the impression that the visit is a social call. Looking at the records the patient registered 2

months ago and was in to get the morning after pill. The consultation from your trainer shows that

visit. The patient has had pain on and off for about 3 days, it suddenly became constant this morning

and it is getting worse. After your surgery you have a cup of tea, grab your bag, and head out.

When you arrive the partner greets you at the door and says the patient is a lot worse; he looks very

worried. He takes you to the bedroom where she is lying in bed. She is slightly sweating and looks to

be in extreme discomfort.

She sits up on the edge of the bed to speak to you. She is complaining of abdominal pain that

started about 7 am this morning. It is very severe and she is very alarmed.


22/47

22 Case 3 Stem 1:


Case 3 Stem 1:

While you are speaking to her she doubles over and falls forward onto the floor. She is verydistressed and writhing in pain.


[Ask the husband to call for an ambulance by 999, ABCD, if possible move her to the

back on to the bed, Vital Signs, Examination]

Question: What is the Differential Diagnosis?

[Ectopic Pregnancy, Ovarian Torsion, Rupturing Cyst, Kidney Stones, Appendicitis

with or without rupture, intussusceptions, volvulus etc.]

Vital Signs: T 36.7 Pulse 150 BP 90/40 RR 18

Question: What is the Differential diagnosis now?

[Ectopic Pregnancy, Ovarian Torsion, Rupturing Cyst, miscarriage]

Exam: The abdomen is tense and bloated she is very tender across the entire lower abdomen

Question: What is the general diagnosis? What is next thing you need to do?

[The general diagnosis is intra-abdominal haemorrhage, if the candidate says they

would like to obtain venous access remind them they are at home and they have no

venflons with them.]

Question: What one piece of information would you like to know from the history?

[LMP, if sexually active?]

Question: What is one investigation that would be helpful for the diagnosis at this time?

[Urine pregnancy Test]

Question: How would you obtain the test?

[Not possible in this setting]

Question: What other exam might be helpful?

[Bimanual Pelvic Exam]

Question: Do you do it?

[Yes with consent and practicable (This is an area of discussion to have with the

^d , will it help it could give information, but does it matter?)]


23/47

23 Case 3 Stem 1:


Question: How many weeks pregnant would you expect the patient to be if she had an

ectopic?

[6 to 8 weeks]

LMP is 7 weeks ago. She did take the morning after pill 6 weeks ago but has not seen a period.

Bimanual/Abdominal exam reveals a tense abdomen (with a right sided adenexal mass.)

Question: Do you give any medication?

[Yes, opiate analgesia preferable IM if you brought it in your bag. The tutor may say

Question: What should the Ambulance be told?

[Diagnosis of intra abdominal bleeding most likely gynaecological e.g. ectopic

pregnancy]

Question: As you are waiting for the ambulance the patient becomes unconscious, what do you

do now?

[ABCD, Vitals]

[Pt is breathing, and you stabilize the Airway Pulse is 200, BP is 60/palp RR 25]

Question: Do you give any medication?

[If the doctor has epinephrine it would be a good thing to give but the tutor may

The paramedic and Ambulance arrive and quickly take her to the closest hospital?


[Ensure that the appropriate service is informed about the patient e.g. gynaecology

at the receiving hospital so they are prepared to received them the ambulance

may do this but you may need to call. Make sure the ambulance is aware of anymedication you have given. Inform them of your working diagnosis]

d

Question: After returning to the practice what do you do?

[Document your visit. Find your trainer and tell them what happened. Discuss what

you did, look at the records and see if there was anything that may have indicated an

urgency, decide if you are going to do to a critical event analysis, set a date for when

you are going to review the evidence that you are gathering and with whom, e.g.

between you and your trainer. Make sure that you will check in on the family overthe coming days to find out what happen to the patient.]


24/47

24 Case 3 Stem 2:


Case 3 Stem 2:

You meet the patient in her bed. She tells you she has felt unwell for a few days but since yesterdaywhen she was a bit feverish and nauseous. She had an upset stomach with lots of pain in her

abdomen. She also thinks she had a temperature and thought she had caught something from one

of her kids. She did not sleep well and she awoke with sudden sharp pain in her right lower

abdomen.

Question: What is your differential at this point?

[Appendix, Gastroenteritis, tubo-ovarian abscess, renal colic/stone, ovarian torsion]

Question: What would you like to know?

[Nature of the pain SOCRATES, concomitant symptoms, vitals, exam]

The pain started as a diffuse pain, but did localize to the RIF. She is feeling increasingly unwell and a

bit faint. She has not eaten and she opened her bowels yesterday. The pain is very localized now,

and it hurts to move.

Vitals T 38.3 P 120 BP 170/95 RR 20

Belly has rebound tenderness with exquisite tenderness in the RLQ. There are no bowel

sounds and the abdomen is slightly distended.

Question: What is the Differential Diagnosis?

[Appendicitis with possible rupture, TOA, PID]

Question: What is the most likely Diagnosis and what do you what to do now?

[Appendicitis, w or w/o rupture, refer to general surgeons and arrange for an

ambulance, you may wish to gain IV access (remind the candidate that they did not

bring the venflons) and provide pain relief depending on advice from the surgeons]

[Option for increasing the Degree of difficulty (This has actually happened to the Author)] You call

the surgeons and you get an SHO who begins to ask you if you have done a PV and says he will not

accept the patient until you have done a PV exam with swabs and a bimanual.

Question: How do you respond?

[The candidate has several options here: He can explain why he thinks its

appendicitis; He can forcefully explain why the patient is coming to him and get his

name and the name of the consultant and tell him to prepare for the patients

arrival; or he can hang up and do the bimanual and call back with the findings of the

bimanual which is basically that it was a difficult exam due to pain but there was no

discharge or pv bleeding and you could not say there was or was not cervical motion

tenderness]

Question: At this point do you give pain control?


25/47

25 Case 3 Stem 2:


[No, because the pain relief could mask the exam and the current attitude of the

surgeon is an indicator that he will not take this patient to surgery]

Question: Out of 100 appendectomies how many should end up removing healthy

appendices?

[20, the diagnosis is difficult to make and the error should be on the presumption of

surgery]

Question: What do you do with the patient while you are waiting for the ambulance?

[The patient needs to be monitored as she may become haemodynamically

unstable. You will need to liaise with reception at the practice to tell the doctors and

your other patients that you are dealing with an emergency on a home visit, your

surgery may be delayed, and they may need to return at a later date or wait if there

problem is urgent.]

The ambulance arrives and takes the patient to casualty.

[The ST should be asked to state what a brief referral letter to casualty should say]


26/47




Patient:

When the doctor arrives you are in a lot of pain in your abdomen. It is constant and severe. If

examined you are tender everywhere and you want him not to touch you. Push his hand away. You

are also not fully /

z

belly is tense and bloated, you are very unwell.

Stem 1:z

stand up. You feel sick and very scared that something is wrong. You greet him sitting on the edge of

the bed doubled over, you quickly lie down and you are in agony drawing up your legs to your belly.

Stem 2: Your additional symptoms are that you are not hungry, you have a fever and you are a bitdelirious. You have not been well for a few days. The pain was very diffuse yesterday then last night

it went to your right side and it was constant and hurt when you moved. If you coughed or moved it

really hurt. This is why you called for a visit this morning. While you were waiting after calling for the

visit the pain intensified and spread across your entire abdomen. It is still very painful on the right

but it is hurting everywhere.

Your partner asked you to call the doctor first thing in the morning, but you were really clear why

she asked you to, she says she is having a lot of belly pain. You called and got some resistance from

'W'Wz

'W st get

^

she is in a lot of pain and she is not very well at all. You have gotten more and more tense since

calling and it takes about 2 hours for the doctor to show up.

You have no idea what is going on but you are very worried. You only moved in with your girl friend

about 3 months ago and you have not been dating for more than 6 months. You are not great on

detail or commitment and you really would rather n There is

no one else in the house except you and your partner (the kids are with their dad). You are a bit

panicked and it takes a moment for you to respond to any requests from the doctor. You were not

with your partner yesterday; you came home late last night from a friend s where you were smoking

some pretty heavy spliffs. zz

afterwards getting home early in the morning. You came in and slept in the sitting room so you

z

bedroom and asked you to call the doctor. If you are directed by the doctor to do something, pause,

take a moment and if yo

z

Stem 1: You and your partner have been a bit risky lately not always using condoms but you know

that she has gone to the doctor for some pills. There was a bit of worry a few weeks ago when she


27/47



Stem 2: no special information needed, except you noticed that she is burning up with fever and is

not acting herself.


28/47

28 Case 4 Collapse in Waiting Room:


Case 4 Collapse in Waiting Room:

Diseases Covered:

x

Stroke (Stem 1)

x Seizure(Stem 2)

x Fracture Neck of Femur (Stem 3)


x Actor/Role Player


x Oxygen Tubing

x AED

x Ambi Bag

x Doctors Bag/Emergency Pack (See Main Materials Section for contents)

Case:

/ rning in your practice and you are on duty in the middle of a busy morning for everyone.

You have several phone calls to return and the waiting room is packed. A receptionist comes to yourt

and runs back to the reception

hall.

Given her reaction you run to the waiting room, as you approach you see a crowd of patients

standing around an elderly patient on the floor. You can see no one is attending to the patient yet.

Question: What do you do? What do you say?

[As the first medically trained person on the scene you need to take charge, you

should ask all everyone to return to their seats, direct by name a receptionist to ask

another doctor and/or Nurse to attend to help you and to bring the emergency bag

and oxygen with them, you should ask another receptionist to call for an Ambulance.

You do this as you begin to assess the patient]


29/47

29 Case 4 Stem 1:


Case 4 Stem 1:

The patient is lying on the floor shaking in tonic-clonic motions.


[ABCD, ask if possible if the waiting room could be cleared or some privacy could be

given to the patient with a screen, apply Oxygen when it comes]

The patient continues to fit but is making shallow breaths, he has a pulse, he has wet himself and is

in a tonic posture with his head back. It feels as though about a minute has past. The practice nurse

arrives with the crash bag and someone has placed a screen around you and the patient.

Question: What medication do you give?

[Diazepam 10 mg rectally, repeat if necessary]

Question: Do you do any tests?

[BM, continue to monitor pulse and breathing]

The BM is 16.

The patient stops having a fit but is unresponsive.

Question: What do you do know?

[Continue to monitor ABC, give oxygen, perform a cursory exam]

The patients exam is a GCS of 13 (have candidate explain the GCS scale, pt responds to verbal stimuli

but is groggy) Pulse 120, BP (take by nurse (180/95) RR 14, Cursory exam show PERRLA, moving all

four extremities, normal heart sounds, there is a small laceration on the patients scalp and there is

d

appear to be any other injuries.


Question: Will the patient need to go to A&E?

[The patient should be placed in the recovery position; you should continue to

monitor the patient where you are; and you should wait for the ambulance. The

patient has had a fit and a head injury and will need to be observed for 6 hours at

z e guaranteed the head injury was from the fit. You should work

with reception to get the rest of the surgery back to running as normally as possible.

You may need to ask for help with the phone calls you need to return, and reception

may need to ask to have patients with non-urgent needs to leave and call in to

reschedule their appointments.]

The Ambulance arrives and takes over, loading the patient onto a stretcher.

Question: What information will the Ambulance need?


30/47

30 Case 4 Stem 1:


[Tell them what happened. If possible p

neuro-observation]

Question: After the ambulance leaves with the patient what do you need to do?

[You need to document what happened in the patients notes; if the patient was not

registered you will need to document what happened somewhere. You should have

a brief chat with the staff involved and set some time aside to review how you

responded as a team and what you could have done better. You need to see if there

are relatives that need to be contacted and do so if possible]


31/47

31 Case 4 Stem 2:


Case 4 Stem 2:

The patient is lying on the floor taking shallow breaths there is blood on the floor as well.


[ABCD, ask if possible if the waiting room could be cleared or some privacy could be

given to the patient with a screen, apply Oxygen when it comes]

The patient is taking shallow breaths, he has a pulse, s/he has wet himself and is unresponsive. It

feels as though about a minute has past. The practice nurse arrives with the crash bag and someone

has placed a screen around you and the patient.

Question: Do you give medication now?

[no, just Oxygen]

Question: Do you do any tests?

[BM, continue to monitor pulse and breathing]

The BM is 4.

Question: What do you do know?

[Continue to monitor ABC, give oxygen, perform a cursory exam]

The patients exam is a GCS less than 9 (have candidate explain the GCS scale, non-responsive) Pulse120, BP (take by nurse (180/95) RR 6 Cursory exam shows left pupil is dilated and fixed, the patient is

taking decerebrate posture to a sternal rub, normal heart sounds, there is a small laceration on the

patients scalp and there is some blood on the floor, the nurse applies a gauze dressing to the

pd


[The patient is having a very severe stroke or subarachnoid haemorrhage, the

patient should be placed in the recovery position if you are certain the C-Spine is

stable; you should continue to monitor the patient where you are you cannot be

z

be guaranteed the head injury was from the fit. You should work with reception to

get the rest of the surgery back to running as normally as possible. You may need to

ask for help with the phone calls you need to return, and reception may need to ask

to have patients with non-urgent needs to leave and call in to reschedule their

appointments.]

Question: What do you do if you think the C-Spine has been compromised?

[Keep the C-spine aligned and roll the patient if you need to clear the airway?]

The Ambulance arrives and takes over, loading the patient onto a stretcher.

Question: What information will the Ambulance need?


32/47

32 Case 4 Stem 2:


d/

notes listing the patients medication, make sure the patient is taken to the local A&E

that can deal with acute stroke/ICH]

Question: After the ambulance leaves with the patient what do you need to do?

[You need to document what happened in the patients notes; if the patient was not

registered you will need to document what happened somewhere. You should have

a brief chat with the staff involved and set some time aside to review how you

responded as a team and what you could have done better. You need to see if there

are relatives that need to be contacted and do so if possible]


33/47

33 Case 4 Stem 3


Case 4 Stem 3

The patient is screaming in agony writhing in pain on the floor but cannot get up he is not moving his

right leg. The patient does not appear to be able to speak English.


[You will not need the oxygen, try to find out what language the patient is speaking

and ask if there is anyone who could translate

language, (The role player should speak gibberish) Try to calm the patient down and

examine the patient cursorily]

d, in.

The practice nurse arrives with the emergency bag.


[Fractured Neck of Femur]

Question: What do you do now? Do you give any medication?

[Give an IM pain killer if available with an anti-emetic. If the practice has a wheel

chair get someone to get it and if possible move the patient from the waiting room.

/


34/47




Patient:

The patient is an elderly person who was waiting to be called to their appointment. There name wascalled on the screen and then went to stand up when all of a sudden you collapse.

Stem 1: You have a short fit for about a minute on the floor, you are unresponsive. After about a

minute you stop but you are relative quiet and unresponsive. You may be replaced by a resuscitation

dummy so the doctor can practice skills. The tutor will direct the case using questions, just go with it.

You are groggy and responding verbally but not using words. You want to be left alone and you are

sleepy.

Stem 2: A dummy can be used for this but if a role player is used they should just lie on the floor

and take a decerebrate posture if stimulated. (The tutor is to demonstrate to the role player beforethe session)

Stem 3:z

(choose a language to use). You went to get up and your leg just gave way and you fell and hit your

head you are slightly stunned but not disorientated. Your leg is in a lot of pain and you are really

angry that it hurts so much. You are a bit cantankerous and want someone to help you and deal with

the pain. If the professionals act appropriately they can calm you down. They will offer you pain

medication, accept it, and let it work except if you are moved which it will still hurt in your let.

Receptionist:You are the only receptionist working at the front desk today due to sickness. You were dealing with

a patient at the desk, when you heard a thud and looked up and saw a patient on the floor of the

waiting room, there was some blood on the floor. You panicked and just ran to the first consultation

room with its door open and said you needed help and ran back to the room. This has never

happened to you and you are a bit miffed that it would happen on the day you are all on your own.

Be available to the doctor to help but if the doctor is not clear ask for clearer instructions.

Other roles:

Unless they are an arriving paramedic/ambulance driver, if others are ask to participate, pleaseensure they understand that they should be more junior doctors to the doctor in charge, e.g.





35/47

35 Case 5 Lifeless Child:


Case 5 Lifeless Child:

Possible Diseases Covered:

x

Respiratory Arrest in a childx Septicaemia


x Actor/Role Player

x Resuscitation Dummy Infant

x Oxygen Tubing

x

AED

x Ambi Bag

x Doctors Bag/Emergency Pack (See Main Materials Section for contents)

Case:

You are working as a duty doctor in a surgery. You are very busy returning calls that morning which

are mostly about the recent influenza outbreak. You see a message flash up on the screen saying you

are needed urgently in reception but you are in the middle of a call and get to it in a second.

All of a sudden, a very distressed mother/father carrying a lifeless infant, storms in to your room

saying help me. S/

The mother is saying, help she is not breathing and she hands you a floppy 11-month infant into your

arms.

The child is floppy and unconscious.

Question: What do you what do you do? What do you want to know?

[You take the child to the examination couch and you check ABCD]

[At the same time you ask the mother what happened.]


36/47

36 Case 5 Stem 1:


Case 5 Stem 1:

d

what happened. The 3 year old was playing with the

infant who was playing with the 3 year old s LEGOS. The infant has just started coasting and was

happily moving around the coffee table when the mother went to answer the phone. When she

walked back into the room the 3 year old was playing and the infant was lying on the floor lifeless.

She just picked up both of them and ran to the surgery which is only across the street.

[The child is lifeless, there is something in the back of the Airway, there is no

respiration to see but there is a pulse]

Question What do you do now? What do you ask for?

[You pick up the child and give five back blows, rechecking the airway between each

set of five as per BLS guidelines]

[You tell the receptionist to call for an ambulance telling them that there is an infant

in respiratory arrest and they need to send a paramedic. You also ask for some help

from another doctor or nurse with the emergency equipment. You tell the

receptionist to come back and tell you it has been done. ]

You check the Airway again and there is a small blue plastic piece just behind the teeth.


[You remove the plastic with a finger sweep and you check ABC again]

The Airway appears open, you place him in the sniff position, but there is no breathing or pulse.


[You start CPR, candidate demonstrates CPR on an infant]

d

Question: What do you say?

[You tell the nurse you are dealing with a respiratory now cardiac arrest and youneed her to bring the oxygen and emergency clinic]

After 2 rescue breaths and one cycle of chest compression you get a pulse and the baby begins

breathing but is still floppy.

Question What do you do now?

[You give the child oxygen and monitor him until the paramedic and ambulance

arrives]

Question: While you are waiting what else do you do?

[Try to speak to the mother about what happened and what is going on, ask about

the other children, make sure the children are being supervised (8 year old at


37/47

37 Case 5 Stem 1:


school, 3 year old is with a receptionist). Ask reception, to tell the rest of the

practice that you are occupied and they need to help with phone calls and any other

emergency that might occur while you are with the child. Get a receptionist to speak

with the parent to help make arrangements for the other children and contact

family]

The paramedic arrives and you hand over to them.

Question: What do you tell them?

[Get the candidate to summarize what has happened in episode in a succinct 2

sentence summary]

The ambulance leaves with the child and mother.


[Take a break, document what has happened, check on everyone else who was

involved and set a time to discuss what happened in more detail. See what has

happened during the time you have been spending with this patient]


38/47

38 Case 5 Stem 2:


Case 5 Stem 2:

dd

for a while and has had a nasty cold. She had a fever last night and they gave the baby calpol and put

here to bed. She slept through the night and was sleeping in this morning but looked ok when they

checked on her at 7 in the morning. After getting the 8 year old off to school and the 3 year old

dressed on off to nursery with dad/mum. She went to check on her a few minutes ago and the child

surgery.

[The child is lifeless and cool and clammy to the touch. The airway is clear there are

very rapid respirations and a thready rapid pulse]


[Expose the child and examine them]

The examination shows that the child is peripherally shut down and there is purpura on the

abdomen and with petechia on the legs arms and chest. There is very little tone.


[Ask for help; get the receptionist to get a nurse or a doctor, the oxygen, the

emergency bag and to call for an ambulance]

Question: What do you tell them to tell the ambulance?

[They need to tell the ambulance you have an infant in severe septic shock you will

need a paramedic and an ambulance]

The nurse arrives with the oxygen and the practice emergency bag.


[Give oxygen by mask, give IM Benzyl-Penicillin ASAP, try to get IV access if you have

a venflon and a fluid bolus of 10mg/kg if possible, monitor the child while the

ambulance arrives]

Question: What do you tell the mother?

[Get the candidate to explain what is happening to the mother in simple language

and what is going to happen next]

The paramedic arrives and you hand over to them.

Question: What do you tell them?

[Get the candidate to summarize what has happened in episode in a succinct 2

sentence summary]

The ambulance leaves with the child and mother.


39/47

39 Case 5 Stem 2:



[Take a break, document what has happened, check on everyone else who was

involved and set a time to discuss what happened in more detail. See what has

happened during the time you have been spending with this patient]


40/47




Parent:

You are very distressed z

her to wake up. You want the doctor to fix it and you are almost hysterical with worry.

Stem 1: When asked what happened you say you went to the phone leaving the 3 year old with

the baby on the mat, the 3 year old had just opened the toy box and was playing the 11 month old

was on the mat just lying on his back. When you came back into the room there were Lego blocks

dumped everywhere and the 11 month old was quiet. You scolded the 3 year old and started to

clean up when you realized something was wrong. You went to the 11 month old and he was lifeless

z ew minutes. You are beside yourself with

grief. You panicked picked up both of the children and ran down the street to the surgery. You ran to

reception and said you needed to see the doctor. z

the 3 year old in reception, when the receptionist asked you to wait because the doctor was on the

phone.

z

doctor speaks to you like he knows what he is doing.

Stem 2: Yod

not feeling that well last night she has had a cold for a while and has had a nasty cold. She had a

fever last night and they gave the baby calpol and put here to bed. She slept through the night and

was sleeping in this morning but looked ok when they checked on her at 7 in the morning. Aftergetting the 8 year old off to school and the 3 year old dressed on off to nursery with dad/mum. She

went to check on her a few min

panicked and just picked up the baby and ran to the surgery. You are beside yourself with grief. You

panicked picked up both of the children and ran down the street to the surgery. You ran to reception

z

year old in reception, when the receptionist asked you to wait because the doctor was on the phone.

Receptionist:

The receptionist should try to calm the mother down and let the doctor work, repeating any

question doctor may ask trying to keep the mother calm.

Other roles:

Unless they are an arriving paramedic/ambulance driver, if others are ask to participate, please






41/47

41 Appendix 1 Pictures:


Appendix 1 Pictures:

Wheals/Urticaria1

Angio-oedema2


42/47

42


Fracture Neck of Femur3

Petechia/purpura4


43/47

43 Appendix 2, Algorithms:


Appendix 2, Algorithms:

Adult Basic Life Support

2 rescue breaths30 compressions


44/47



AED Algorithm


45/47




46/47



PBLS Algorithm:

15 chest compressions

2 rescue breaths


47/47

47 References:

References:

General Resources:

Riley B, Hayne J and Field S, The Condensed Curriculum Guide RCGP September 2007

RCGP Curriculum Documents:http://www.rcgp-

curriculum.org.uk/rcgp_curriculum_documents.aspx

Kingston PCT, The Orange Book: Advice on the management of common medical emergencies

in primary care January 2005

Algorithms From:

Resuscitation Council UK 2005http://www.resus.org.uk/pages/gl5algos.htm

Image Credits:

1. Urticaria/Wheals: Global Pinoy,

http://www.globalpinoy.com/images/pinoyhealth/FirstAid/anaphylaxis.jpg

2. Angio-oedema and urticaria Wheals, The Anaphylaxis Campaign: offering help and

information for patients at risk of anaphylaxis http://www.sovereign-

publications.com/anaphylaxis.htm

3. Fracture Neck of Femur, Utah Mountain Biking.comhttp://www.utahmountainbiking.com/firstaid/fxhip.htm

4. Petechia and purpura: WebMD, http://www.webmd.com/a-to-z-guides/sepsis-blood-

infection?page=3
http://www.rcgp-curriculum.org.uk/rcgp_curriculum_documents.aspxhttp://www.rcgp-curriculum.org.uk/rcgp_curriculum_documents.aspxhttp://www.rcgp-curriculum.org.uk/rcgp_curriculum_documents.aspxhttp://www.rcgp-curriculum.org.uk/rcgp_curriculum_documents.aspxhttp://www.resus.org.uk/pages/gl5algos.htmhttp://www.resus.org.uk/pages/gl5algos.htmhttp://www.resus.org.uk/pages/gl5algos.htmhttp://www.globalpinoy.com/images/pinoyhealth/FirstAid/anaphylaxis.jpghttp://www.globalpinoy.com/images/pinoyhealth/FirstAid/anaphylaxis.jpghttp://www.sovereign-publications.com/anaphylaxis.htmhttp://www.sovereign-publications.com/anaphylaxis.htmhttp://www.utahmountainbiking.com/firstaid/fxhip.htmhttp://www.utahmountainbiking.com/firstaid/fxhip.htmhttp://www.utahmountainbiking.com/firstaid/fxhip.htmhttp://www.sovereign-publications.com/anaphylaxis.htmhttp://www.sovereign-publications.com/anaphylaxis.htmhttp://www.globalpinoy.com/images/pinoyhealth/FirstAid/anaphylaxis.jpghttp://www.resus.org.uk/pages/gl5algos.htmhttp://www.rcgp-curriculum.org.uk/rcgp_curriculum_documents.aspxhttp://www.rcgp-curriculum.org.uk/rcgp_curriculum_documents.aspx