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Home > Simulations > Simulation 4: Brazilian Immigrant

Scenario #4: Brazilian Immigrant, Mr. José Eduardo Silva

José Eduardo Silva

Learner Group: Physician or Nurse, Physical Therapy, Social Work

Environment: Inpatient telemetry floor/ Acute Care

Authors: K. Panzarella; J. Myers

Facilitator directions

Main focus

  1. Recognition of symptomatic bradycardia
  2. Manage a patient with symptomatic bradycardia including treatment and disposition
  3. 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

  1. Transcutaneous pacing
  2. Patient education on need for angiogram
  3. Interprofessional communication

Imbedded challenges

  1. Change in patient status
  2. Patient persistent in wanting to get out of bed
  3. Patient requesting early discharge

Learners roles & staging

Role Staging Info Given
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?

Patient information

Name: Mr. José Eduardo Silva
Age: 55 years old
Height: 6 foot 0 inches
Gender: Male
Religion: Roman Catholic
Social: Immigrant from Brazil, 4 years ago
Support: Married, wife not present today

Medications

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.

Social history

Former smoker, quit 15 years ago. Social alcohol use monthly.

Report to participants (give info to participants separately)

Physician/Nurse

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.

Physical Therapist

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.

Social Worker

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
Gender Male
Clothes Hospital gown, underwear, Brazil baseball cap
Position Seated
Moulage none
Environment Telemetry floor
Equipment Attached to telemetry monitor, monitor on Transcutaneous pacer/defibrillator
Disposable Supplies
IV Hep trap Normal saline bag & line
Medications

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
0-7 Minutes Initial at 3 minutes
HR 60 same
Rhythm Normal sinus
RR 16
O2 Sat 98%
Breath Sounds Clear
B/P 140/82
Temp 37.2
Bowel Sounds Normal
Mental Status Alert

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!

  • Physician compassionately reviews results with the patient
  • Physician educates patient regarding need for angiogram and the procedure in lay terms
  • Physician positively acknowledges Physical Therapist when (s)he enters the room and when asked about orders
  • Physician does not change bed rest order due to elevated troponin

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!'

8-15 Minutes Initial
HR 28
Rhythm Sinus
RR 22
O2 Sat 96%
Breath Sounds Clear
B/P 80/40
Temp 37.2
Bowel Sounds Normal
Mental Status Alert

Tone: patient severely lightheaded

Script: "What the heck is going on? I'm not feeling good, I gotta get out of this bed!'

  • Physician identifies change in patient status within one minute of change
  • Physician rapidly reassesses patient within two minutes of change in status and identifies symptomatic bradycardia requiring intervention
  • Team calls for assistance
  • Physical Therapist asks how (s)he may be of assistance
  • Transcutaneous pacemaker ordered to bedside
  • Physician considers trial of atropine 0.5 mg IV administered once or twice
  • Physician orders transcutaneous pacing if atropine is ineffective
  • Physician orders sedation and / or analgesia for patient to prepare for transcutaneous pacing
  • Social Worker enters the room to talk to Mr. Silva about the necessity of his hospital stay
Nurse comes in once called or code button pressed

If/then chart

IF Cardiac Respiratory Diagnostic Other
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
Opening

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?
Medication Administration*

Atropine

Sedation prior to transcutaneous pacing

What medications could be considered? In what order should they be given? How?
Communication*

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?

Closing

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)

References

(References for students regarding the clinical scenario)

  1. Circulation, November 3, 2010 supplement, Section 10: Acute Coronary Syndrome
  2. Circulation, November 3, 2010 supplement, Section 8: Acute Cardiac Life Support

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