Scenario #3: Haitian Immigrant, Mr. Emmanuel Herling
Learner Group: OT, PT, Physician (can be a confederate), nurse (can be confederate)
Environment: Outpatient Rehabilitation Center, within the hospital
Authors: K. Panzarella; J. Myers
- Recognition of Acute Coronary Syndrome in a patient who has L shoulder pain
- Manage a patient with an acute coronary syndrome including treatment and disposition
- Manage a patient who has a different cultural background from the learner and is refusing to go to ED
|C/T/B||Main focus||Performance measures|
|1||B||1||Physical Therapist obtains a sufficient history to determine the need for acute medical intervention within 2 minutes of the start of pain without L upper extremity movement|
|2||C/B||1||PT/OT accesses help within 2 minutes of the start of pain|
|3||T||2||PT/OT assesses vitals on patient immediately after change of status|
|4||T||2||PT/OT lays patient down on the exam table|
|5||T||2||Physician acquires a 12 lead ECG within 2 minutes of arrival|
|6||C/B||2||If not already performed, Physician requests assessment of vital; signs including pulse oximetry, blood pressure, pulse and respiratory rate|
|7||B||3||A hand off report is provided to new professionals who arrive at the bedside using an SBAR format|
|8||B/T||2||Physician performs a rapid history and physical focused on the cardiovascular and respiratory systems within two minutes of arrival|
|9||C/B||2||Team maximizes resource utilization|
|10||T||2||Team initiates supplemental oxygen if SaO2 < 94%|
|11||T||2||Team administers nitroglycerine tablets is patient's systolic blood pressure is above 100 mmHg|
|12||B/T||2||Team initiates / requests IV access|
|13||B/T||3||Teams requests movement of patient to the Emergency Department|
|14||B||2||Blood work: Chemistry, troponin, CBC, coags, (+/- myoglobin)|
|15||C/B||2||Orders Chest Xray|
|16||T||2||The team administers chewable aspirin between 162 mg and 324 mg within 5 minutes of identification of ACS|
|17||T||2||Physician correctly identifies ischemia on the 12-lead ECG|
Synopsis of Scenario
Mr. Emmanuel Herling is visiting the outpatient rehabilitation department of the hospital for treatment of a Left shoulder problem that began with a motor scooter crash a year ago in Haiti. Mr. Herling is 64 years old and immigrated from Haiti following the earthquake and speaks limited English. He exacerbated the injury while building his home two months ago and was referred to occupational and physical therapy. When he presents during the initial interview with the physical therapist, he complains that his shoulder pain increased while he was waiting for his appointment and is radiating to his upper left chest and left arm. This radiation is new and is not related to movement or position. The OT arrives to see when the patient will be ready for OT evaluation. The patient is having an acute coronary syndrome on top of his existing musculoskeletal injury. The patient asks if he should take one of his nitroglycerine tablets which he has in his pocket. The physical therapist activates the rapid response team who arrives. The patient is reluctant to go up to the ED but consents with maximal discussion. The patient should be moved to the ER rapidly. An ECG shows evidence of ischemia. The patient is treated for ACS and admitted to the hospital pain free.
- Focused history and physical
- Communication between OT and PT
- Call for help or move to ED
- Location in the physical therapy department with limited medical / diagnostic resources
- Patient reluctant to go to the ED
- Chest pain is similar to prior musculoskeletal pain but represents an Acute Coronary Syndrome
Learners Roles & Staging
|Physical Therapist||Hallway||"Mr. Herling is here for initial eval for a shoulder problem, referred from his physician, here is his chart."|
|Occupational Therapist||Hallway||"When PT starts their evaluation with Mr. Herling you will join and inquire about an OT evaluation as well"|
|Physician||Hallway, responds with rapid response team||"Rapid response to outpatient physical therapy."|
Confederate Roles & Scripting
|Role||Tone||Timing of participation||Lines / Comments|
|Nurse||Helpful||Arrives 1 - 2 minutes after medical student||"I'm your nurse, how can I help?"|
Name: Emmanuel Herling
Age: 55 years old
Height: 6 foot 0 inches
Support: Married, wife not present today
Naproxyn 500 mg twice daily
Nitroglycerine tablets (hasn't used in two years)
Aspirin daily was stopped when the NSAID was started
History of present illness
Has chronic Left shoulder pain after a scooter accident a year ago in Haiti, no treatment was provided. This injury was exacerbated two weeks ago when the patient was clearing brush at his rural property. He saw his physician last week who prescribed him naproxyn and referred him back to physical therapy. This is his first visit. At the beginning of the encounter, he states that his pain became worse while in the waiting room and its now radiating into his upper left chest and upper left arm. This is new for him. The pain is not modified by movement and is somewhat squeezing / aching in nature.
Past medical history
Had an episode of chest pain and stress test two years ago that was negative. He was prescribed nitroglycerine but has not had to use it. Patient had a scooter crash a year ago and suffered a left rotator cuff tear that was not treated in Haiti.
Former smoker, quit 15 years ago. Social alcohol use monthly. Patient moved here from Haiti six months ago following the Haitian earth quake. Patient has just purchased a small home in the country with his wife and four children and is anxious the repairs he needs to do to the home.
Report to participants
Report to PT/OT student
You are working at an outpatient but hospital based physical therapy office. You are sent in to see Mr. Herling who is here for a physical therapy evaluation for Left shoulder pain. He had a left rotator cuff tear after a scooter crash a year ago in Haiti and had a recent exacerbation of his injury. He also is inquiring about an OT evaluation. Here is his chart.
Report to medical student
You are working on the medical ward on the internal medicine service and are part of the rapid response team to respond to emergencies within the hospital.
Technician Staging Directions
|Staged for learners||Available for learners to use|
|Manikin||Seated on exam table, Dark skin coloring for Haitian decent|
|Clothes||Street clothes, shirt with front packet for meds, Baseball cap|
|Environment||Outpatient physical therapy room (murphy bed or plinth)|
|Disposable Supplies||Usual room supplies|
|IV||Hep trap & IV normal saline line|
|Medications||Nitroglycerine tablets in patient's pocket||
Nitroglycerine 0.4 mg tablets
Aspirin 81 mg tablets - 4
Nitroglycerine ointment - 1 tube
Enoxoparin 100 mg SQ
|Labs||All labs normal including troponin (upon request)|
|Xray||CXR normal (upon request)|
|Other Diagnostics||ECG - reveals ischemia (upon request)|
|Chart Records||Script from primary physician to physical therapist for referral for left shoulder pain, also OT evaluation||Blank ED chart/orders|
Progression of events
|Manikin Actions||Performance Measures||Cues/Confederates|
Significant pain in shoulder
Patient: "Boy, my shoulder hasn't hurt this bad before but I need to get home soon to work on my house"
If asked, pain is 8:10
When asked, "Today the pain feels different. It hurts all the time, not just when I move my arm."
If not asked by 5 min, the patient states his pain is increasing and asks if he should take his own nitroglycerine tablets
If nitroglycerine given, patient is calmer & more relaxed.
Patient: "What's going on doc?"
Patient: " I don't want to go anywhere, I need to go home to work on my house"
||Nurse: "Should we move this patient to the ED?"|
|1||Nitroglycerine administer||BP decreases 5%||RR = 16||Pulse decreases 5%; pain resolves|
Integrated debriefing guide
|Threads||Performance Measures/Discussion Points||Debriefing Prompt|
Someone give us a quick summary of what was going on with this patient.
What went well?
What didn't go so well?
|Understand clinical presentation||
Differentiation between musculoskeletal and cardiac cause of shoulder pain
Physician correctly identifies ischemia on the 12-lead ECG
|What signs and symptoms could we expect for this type of patient?|
|Recognize a change in patient status*||PT/OT identifies ACS||Looks/sounds like things are changing - what is concerning at this point?|
|Identify correct intervention / treatment*||
Physician acquires a 12 lead ECG within 2 minutes of arrival
IV access requested within 2 minutes
What are some standards of care for this type of patient?
What other options for care would be reasonable?
Vital signs including pulse oximetry, blood pressure, pulse and respiratory rate.
PT/OT obtains a sufficient history to determine the need for acute medical intervention within 2 minutes
Physician performs a rapid history and physical focused on the cardiovascular and respiratory systems within two minutes of arrival.
Orders Chemistry, troponin, CBC, coags, (+/- myoglobin) and Chest X-Ray
Thoughts about types of specific assessments that are important for this patient...
What are priorities for this patient?
How might variation of pain be reported differently due to one's culture?
|Infection Control||What infection control practices would we need to consider?|
Administer Nitroglycerine, aspirin
Oxygen not required as SaO2 is always above 94%
|What medications could be considered? In what order should they be given? How?|
|Patient Safety||PT/OT lays patient down on the exam table||Talk about some concerns and options on how we could keep this patient safe...|
|Documentation||What information would we want to document? What are strategies for doing that during a crisis?|
|Communication*||A hand off report is provided to new professionals who arrive at the bedside using an SBAR format||As a newcomer to the patient situation, what information would be helpful? Lets practice giving an SBAR about this patient...|
Patient is new immigrant from Haiti
Patient is concerned with responsibility to work on his home
What might be some considerations about this patients previous medical treatment in Haiti?
How does his culture or beliefs impact this case?
Discuss some strategies to prevent us from becoming task focused...
What resources could be accessed for help?
|Decision Making Prioritization*||
Team maximizes resource utilization
Team requests movement of patient to the Emergency Department
Patient declines movement to ED
How were decisions made?
How can we convince the patient to move to ED?
|Leadership*||How were roles delegated? How was leadership established? What actions did the leader take to ensure situational awareness?|
How were we coming across?
What are some strategies for managing difficult interactions?
What would we do differently next time?
What would we do if this outpatient clinic was not based in a hospital setting?
Does anyone have any additional questions or comments?
* = typical event to stop/review with video replay
Take Home Messages
(Bullet point main clinical take home messages)
- Keep an open differential especially for pain that is not typical for the patient's musculoskeletal complaint
- Need to gain patient trust even in emergency situation to gain adherence
- Communicate with other team members to decide on roles in emergency situation
- Rapid acquisition of a 12 Lead ECG identifies appropriate treatment pathway for a patient with ACS
- Ischemia was identified on this patient's ECG by the ST segment depression in leads V3 through V6 and I and aVL.
- Appropriate treatment for this patient includes:
- Aspirin 162 - 325 mg
- Nitroglycerine 0.4 mg sublingual
- Anticoagulant with either enoxaparin or heparin
- Apply supplemental oxygen if:
- SaO2 < 94%
- Signs of acute pulmonary edema
- Consider movement to a monitored area early. The exact timing and destination depends on the facility, however often outpatients are brought to the emergency department.
(References for students regarding the clinical scenario)
- Circulation, November 3, 2010 supplement, Section 10: Acute Coronary Syndrome