Scenario #4: Brazilian Immigrant, Mr. José Eduardo Silva
Learner Group: Physician or Nurse, Physical Therapy, Social Work
Environment: Inpatient telemetry floor/ Acute Care
Authors: K. Panzarella; J. Myers
- Recognition of symptomatic bradycardia
- Manage a patient with symptomatic bradycardia including treatment and disposition
- Manage a patient whose cultural beliefs may impact his health care decisions
|C/T/B||Main Focus||Performance measures|
|1||B||2||Physician compassionately reviews results with the patient|
|2||C/B||2||Physician educates patient regarding need for angiogram and the procedure in lay terms|
|3||B||2||Physician positively acknowledges Physical Therapist when (s)he enters the room and when asked about orders|
|4||B||2||PT acknowledges that Physician does not change bed rest order due to elevated troponin|
|5||C||1||Physician identifies change in patient status within one minute of change|
|6||T||1||Physician rapidly reassesses patient within two minutes of change in status and identifies symptomatic bradycardia requiring intervention|
|7||B||3||PT and physician realize patient is not compliant with bed rest orders and inquire further|
|8||B||1||Team calls for assistance|
|9||B||3||Physical Therapist asks how (s)he may be of assistance and continues to gain patient compliance|
|10||C||1||Transcutaneous pacemaker ordered to bedside|
|11||T||1||Physician considers trial of atropine 0.5 mg IV administered once or twice|
|12||C||1||Physician orders transcutaneous pacing if atropine is ineffective|
|13||C/T||2||Physician orders sedation and / or analgesia for patient to prepare for transcutaneous pacing|
|14||B||3||A hand off report is provided to new professionals who arrive at the bedside using an SBAR format|
|15||B||2||Team maximizes resource utilization including physician, social worker, physical therapist or other providers|
Synopsis of scenario
Mr. José Eduardo Silva was admitted with a non-ST Elevation STEMI yesterday. He was at his physical therapy appointment when he began having Left upper chest & arm pain. His initial ECG showed ischemia. He was admitted to the telemetry floor with negative enzymes. Later that evening, his second Troponin was above the threshold for myocardial infarction. He is pain free and feeling better. He is scheduled for an angiogram and probable angioplasty tomorrow. The physician or nurse comes in to tell Mr. Silva that he will need an angiogram tomorrow because his cardiac enzyme just came back elevated and he did have a myocardial infarction. The Physical Therapist comes in with an order to treat the left shoulder pain. The patient asks to get out of bed and walk with the Physical Therapist (orders state bed rest orders say mobilize shoulder). The patient is adamant about getting out of bed, says he feels fine and wants to go home, he has a trip planned to his home country of Brazil for Carnival at the end of the week and just wants his shoulder to feel better.
After the initial contact between the physician and physical therapist, Mr. Silva becomes lightheaded, begins to have more chest pain and his heart rate drops from the upper 50s to the low 30s. The symptoms are worse sitting up and the lightheadedness improves when lying flat. The social worker enters the room as Mr. Silva's symptoms are increasing.
The patient does not improve if atropine is given. The patient improves once transcutaneous pacing is initiated
Skills / tasks / procedures
- Transcutaneous pacing
- Patient education on need for angiogram
- Interprofessional communication
- Change in patient status
- Patient persistent in wanting to get out of bed
- Patient requesting early discharge
Learners roles & staging
|Physician/Nurse||Hallway||Elevated troponin, angiogram scheduled, go tell Mr. Silva|
|Physical therapist||Hallway||Order for PT left shoulder (chart for the physical therapist)|
|Social Worker||Hallway||Order to counsel patient to prepare for angio and not seek discharge|
Confederate roles & scripting
|Role||Tone||Timing of participation||Lines / Comments|
|Nurse||Professional||When called for by team||
What can I do to help?
What do you need?
Do you want something for the heart rate?
Name: Mr. José Eduardo Silva
Age: 55 years old
Height: 6 foot 0 inches
Religion: Roman Catholic
Social: Immigrant from Brazil, 4 years ago
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
Mr. José Eduardo Silva has chronic Left shoulder pain after a car accident a year ago, successfully treated. This injury was exacerbated two weeks ago when the patient was replacing the roof on his home. He saw his physician last week who prescribed him naproxyn and referred him back to physical therapy. Mr. Silva attending his first physical therapy visit yesterday and stated that his L shoulder pain became worse while in the waiting room and its now radiating into his upper left chest and upper left arm. The pain is not modified by movement and is somewhat squeezing / aching in nature. This was new for him. After coaxing from the PT and a MD who was in the vicinity, he was escorted to the ED and admitted for more testing to rule out an MI.
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 has a car crash a year ago and suffered a left rotator cuff tear that was treated with physical therapy.
Former smoker, quit 15 years ago. Social alcohol use monthly.
Report to participants (give info to participants separately)
You are following Mr. Silva who was admitted last night for rule out acute coronary syndrome. His second troponin came back at 0.5 which is above the limit indicating he had a myocardial infarction. You need to go in and inform him of the test result, that he is scheduled for an angiogram tomorrow, and answer any questions he has regarding the procedure.
Just received an order for PT to left shoulder while on bed rest. You enter the patient's room to evaluate and carry out the PT orders.
You are visiting Mr. Silva to work with him and his family regarding his hospital stay. The nursing staff has called you to inform you that Mr. Silva wants to leave the hospital against medical advice because he is scheduled to return to Brazil next week for Carnival.
Technician staging directions
|Staged for learners||Available for learners to use|
|Manikin||Sitting in bed|
|Clothes||Hospital gown, underwear, Brazil baseball cap|
|Equipment||Attached to telemetry monitor, monitor on||Transcutaneous pacer/defibrillator|
|IV||Hep trap||Normal saline bag & line|
In the code cart:
Atropine Syringes prefilled 0.5 mg each
Epinephrine Syringes 1 mg prefilled syringes
Dopamine 1 500 mL IV bag 400 mg/500 mL concentration
Dobutamine 1 500 mL IV bag, 800mg/500ml concentration
|Labs||In chart blood work from ED and from earlier today (all chart components available upon staging)|
|Xray||Result in chart from last night|
|Other Diagnostics||ECG from last night and today|
|Chart Records||Orders include bedrest with PT for L shoulder mobilization|
|Monitor||Connected: EKG, Pulse Ox, BP, RR, Pulse|
Progression of events
|Manikin Actions||Performance Measures||Cues/Confederates|
Tone: Patient wants to get out of bed, becomes more anxious when told about the angiogram
Script: I don't want the test, I'm going to my home country of Brazil in 3 days. I must go back home for Carnival!
When told about angiogram, patient becomes anxious, asks for explanation, wants to leave the hospital AMA
Physical therapist enters room by 5 minutes. Patient asks if physical therapist can get him out of bed, wants to go home. "I came here for my shoulder and then all this craziness happened!'
Tone: patient severely lightheaded
Script: "What the heck is going on? I'm not feeling good, I gotta get out of this bed!'
||Nurse comes in once called or code button pressed|
|1||Atropine given||No change||No change||No change||No change|
|2||Transcutaneous pacing initiated||Capture occurs at about 90mA at a rate of 70, blood pressure increases to 110/50||Drops to 16||No change||Patient becomes less anxious|
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||Physician rapidly reassesses patient within two minutes of change in status and identifies symptomatic bradycardia requiring intervention||What signs and symptoms could we expect for this type of patient?|
|Identify contributing factors||Describe some contributing risk factors we should consider...|
|Recognize a change in patient status*||Physician identifies change in patient status within one minute of change||Looks/sounds like things are changing - what is concerning at this point?|
|Identify correct intervention / treatment*||Atropine, transcutaneous pacing||
What are some standards of care for this type of patient?
What other options for care would be reasonable?
|Assessment*||Physician rapidly reassesses patient within two minutes of change in status||
Thoughts about types of specific assessments that are important for this patient...
What are priorities for this patient?
|Infection Control||What infection control practices would we need to consider?|
Sedation prior to transcutaneous pacing
|What medications could be considered? In what order should they be given? How?|
A hand off report is provided to new professionals who arrive at the bedside using an SBAR format
Physician compassionately reviews results with the patient and educates patient regarding need for angiogram and the procedure in lay terms
As a newcomer to the patient situation, what information would be helpful? Lets practice giving an SBAR about this patient...
What are some strategies for handling difficult patients?
How might this patient's culture impact upon his behavior?
|Situational Awareness*||Team maximizes resource utilization including, physical therapist, social worker or other providers||
Discuss some strategies to prevent us from becoming task focused...
What resources could be accessed for help?
How might this patient's culture impact upon his behavior?
What can we do to address his cultural preferences?
|Decision Making Prioritization*||How were decisions made?|
|Leadership*||Use of PT and social worker||How were roles delegated? How was leadership established? What actions did the leader take to ensure situational awareness?|
|Professional Behavior*||Physician positively acknowledges Physical Therapist when (s)he enters the room and when asked about orders, acknowledges social worker||
How were we coming across?
What are some strategies for managing difficult interactions?
What would we do differently next time?
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)
- A Non-ST Elevation Myocardial Infarction (NSTEMI) is indicated by a troponin that is elevated above the cut off for a myocardial infarction in the absence of ST Elevations on the ECG
- Troponin can take between 6 and 8 hours to elevate in the serum after myocardial cell death. This is the reason for "cycling the trops' or taking repeated values to rule in or rule out myocardial infarction.
- Symptomatic bradycardia is defined as bradycardia that is accompanied by:
- Severe chest pain
- Poor perfusion
- Altered mental status
- Acute pulmonary edema
- Atropine is a first line medication and can be administered in 0.5 mg increments. Transcutaneous pacing should be instituted if atropine is not effective in improving blood pressure and alleviating symptoms.
- Sedation is an important component of transcutaneous pacing as it is uncomfortable
- The transcutaneous pacer is set for a rate of 70 and roughly 80-100 mA until capture occurs.
- Utilize resources, including other health professions to work together in managing the patient
- Cultural considerations and priorites
(References for students regarding the clinical scenario)
- Circulation, November 3, 2010 supplement, Section 10: Acute Coronary Syndrome
- Circulation, November 3, 2010 supplement, Section 8: Acute Cardiac Life Support