Scenario #5: Brazilian Transnational, Mr. Giovani Acquarone
Learner Group : Nursing Student or Medical student, Physical Therapy and/or Occupational Therapy
Environment: Hospital Lobby outside Rehabilitation Department
Authors: K. Panzarella; J. Myers
- Rapidly identifying a cardiac arrest
- Manage a patient in sudden cardiac arrest
- Manage a patient found to be in possession of drugs and a fire arm
|C/T/B||Main Focus||Performance measures|
|1||C/T||1||Assess for signs of life within 30 seconds of contact of patient|
|2||T||2||Initiate compressions within 30 seconds of contact, performing them in accordance with AHA recommendations|
|3||B||2||Communicate among team members using SBAR, callouts and read backs|
|4||C/B||2||Call for crash cart and additional resources|
|5||T||2||Attach the defibrillator / monitor to the patient|
|6||T||2||Initiate IV access|
|7||C||2||Correctly identify ventricular fibrillation|
|8||T||2||Defibrillate the patient at 120 joules each shock|
|9||B||2||Insure all providers are clear of the patient prior to defibrillation|
|10||C/T||2||Initiate airway management after at least two rounds of CPR|
|11||T||2||Compressors switch and check pulse at least every two minutes|
|12||T||2||Administer epinephrine 1 mg after the first shock|
|13||C/T||2||Reassess patient after return of circulation|
|14||T||2||Move the patient from the floor to the stretcher in a coordinated fashion using accepted body mechanics|
|15||B||2||Continue to inform the patient of movements / activities|
|16||T||2||Ventilate the patient using either bag mask or an airway device following AHA guidelines after return of circulation|
|17||C/T||2||Once pulse returns, transfer to the Emergency Department is initiated within 3 minutes|
|B||3||Once it is discovered that patient is in possession of firearm, work with wife to resolve|
Synopsis of scenario
A "Code Blue" is called in the hospital lobby just outside the rehabilitation department. Two therapists respond to the patient, from the rehabilitation department. The patient is in cardiac arrest without a pulse or breathing. The medical team arrives three minutes later. The patient is found in ventricular fibrillation when the monitor is attached. The patient is defibrillated twice and has a return of circulation and a sinus rhythm. The patient should then be moved to the emergency department. The patient's wife arrives during the code and is fanatical that he needs to fly out to Brazil this afternoon and does not want his clothes removed. When the patient shirt is opened a conceded firearm is detected.
Skills / tasks / procedures
- Cardiac Rhythm interpretation
- Bag valve mask
- Advanced airway management
- Medication administration
- Patient lifting and moving
- Team work and communication
- On a floor in a non-patient area of the hospital
- Unfamiliar team
- No crash cart in sight initially
- Patient is non-responsive - no family for information
- Patient's wife arrives during code and is fanatical about not removing her husband's clothing
Learners roles & staging
|1||Physical Therapist /Occupational Therapist #1&2||Hallway||You go out into the waiting room to retrieve your next patient. Code Blue called in lobby outside the rehabilitation department. You are the first to arrive|
|2||Physician or Nurse #1||Hallway||Code Blue called in lobby outside rehabilitation therapy department, you arrive 3 minutes after the code was called|
|3||Physical Therapist or Occupational Therapist #3||Hallway||Enters scene with PT #1&2: Same info as above but told separately that after more people arrive, you recognize the patient as Herman Smith, who you have been working with for several weeks for a exacerbation of Multiple Sclerosis|
|4||Physicians #2||Hallway with code cart||Code Blue called in lobby outside physical therapy department. You are responsible for bringing the code cart|
Confederate roles & scripting
|Role||Tone||Timing of participation||Lines / Comments|
|Wife||Excited||Arrives after medical team||
"Oh my God, just went to get a coffee, what is going on with Giovani? "
"Please don't call the police"
Name: Giovani Acquarone
- Lisinopril 10 mg daily
- Digoxin 0.125 mg daily
- Metformin 500 mg twice daily
- Furosemide 20 mg twice dailyclose
History of present illness
Mr. Acquarone just finished a visit to the PT department for an exacerbation of his MS symptoms and was waiting in the lobby for his wife to pick him up when he started to feel lightheaded. He then passed out and the person sitting next to him called for help.
Past medical history
Multiple Sclerosis, Myocardial infarction three years ago with coronary artery bypass graft performed. Atrial fibrillation controlled with digoxin. Systolic heart failure with an Ejection Fraction of 40%
- Smoker, 2 - 3 packs per day
- Uses alcohol regularly on a daily basis
- Prior incarceration for armed robbery
Report to participants
I will indicate when each of you should proceed in to the room.
You are part of the hospital's code response team. An overhead announcement for a "Code Blue" in the hospital lobby. You are in one section of the lobby and will be the first person to arrive.
Physical /Occupational Therapists (all)
You hear an overhead announcement for a "Code Blue" located in the hospital lobby. You respond to help since you are steps away from the patient.
Physical or Occupational Therapist #3 (separately from the other two)
About 5 minutes after you arrive, for your next patient, you recognize the patient in distress as Giovani Acquarone, a 57 year old male you just treated to treat this past week for exacerbation of his MS symptoms. You recall he has a cardiac and diabetes history and lives half his time in Brazil, but not much else.
Physicians #2 & #3
You hear an overhead announcement for a "Code Blue" in the hospital lobby. You work in the ER which is the nearest clinical unit to the lobby. You grab the code cart in the ER and respond to the code.
Technician staging directions
|Staged for learners||Available for learners to use|
|Clothes||Street clothing, loose preferred but not necessary, hand gun concealed under shirt with chest holster|
|Position||Supine on ground.|
|Environment||Hospital lobby. Bed is masked so it is not available initially. 2 or 3 chairs set up to simulate a waiting area|
|Equipment||Code cart in hall brought in by assigned individuals|
|IV||IV start kit, trap and normal saline 1 liter bags|
In code cart:
Epinephrine 1 mg prefilled syringes
Atropine 0.5 mg prefilled syringes
Amiodarone 150 mg / 2 mL vial
Dopamine 400mg/500mL concentration
|Other Diagnostics||ECG if requested shows anterior wall ST Elevation Myocardial Infarction|
Blank code summary sheet available in code cart
Blank ED chart available in code cart
Progression of events
|Manikin Actions||Performance Measures||Cues/Confederates|
Script: None, unconscious
Physician #1 enters first.
OT/PT therapy team enters 2 minutes later.
Physicians #2&3 enter 2 minutes after PT team with crash cart.
Nurse arrives 2 minutes after Physicians
After second defibrillation, start pulse per IF/THEN Table
Wife enters frantic, concerned about calling authorities about handgun
|1||Defibrillation #1||Stays in ventricular fibrillation|
|2||Defibrillation #2||Rhythm changes to normal sinus rhythm at 90 bpm and blood pressure of 90/50||If capnography applied, then EtCO2 jumps to 45 mmHg|
|3||Waveform capnography applied after intubation||Waveform shows an EtCO2 of 25 mmHg|
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||What signs and symptoms could we expect for this type of patient?|
|Recognize a change in patient status*||
Correctly identify ventricular fibrillation
Reassess patient after return of circulation
|Looks/sounds like things are changing - what is concerning at this point?|
|Identify correct intervention / treatment*||
Initiate compressions within 30 seconds of contact, performing them in accordance with AHA recommendations
Defibrillate the patient at 120 joules each shock
Ventilate the patient using either bag mask or an airway device following AHA guidelines after return of circulation
What are some standards of care for this type of patient?
What other options for care would be reasonable?
|Understand cultural implications||
How does team react when the handgun is discovered
How does team respond to wife's concerns about the authorities?
What thoughts do we have about how this patient's beliefs may impact outcomes?
When is it appropriate to involve the authorities? What other information would you like?
|Assessment*||Assess for signs of life within 30 seconds of contact of patient||
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*||Administer epinephrine 1 mg after the first shock||What medications could be considered? In what order should they be given? How?|
Insure all providers are clear of the patient prior to defibrillation
Move the patient from the floor to the stretcher in a coordinated fashion using accepted body mechanics
Talk about some concerns and options on how we could keep this patient safe...
How did the transfer go?
|Documentation||What information would we want to document? What are strategies for doing that during a crisis?|
|Communication*||Communicate among team members using SBAR, callouts and read backs||
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 family members?
|Situational Awareness*||Once pulse returns, transfer to the Emergency Department is initiated within 3 minutes||
Discuss some strategies to prevent us from becoming task focused...
What resources could be accessed for help?
|Decision Making Prioritization*||How were decisions made?|
|Leadership*||Call for crash cart and additional resources||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?
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)
- Initial assessment looks for signs of life
- Initiate compressions quickly after identifying the absence of signs of life
- Utilize your resources to help including bystanders and other health professionals
- Succinct reports to other health professionals keeps the entire team on the same page during resuscitation
- Response to finding handgun on patient
- Utilizing team to respond to frantic wife
- It is acceptable to delay airway management for two cycles of CPR
- Defibrillate at the maximum energy setting for the defibrillator
- Acquire a 12 lead ECG as soon as possible after return of spontaneous circulation (ROSC) in order to rapidly identify those patients who would benefit from primary angioplasty or fibrinolytics
(References for students regarding the clinical scenario)
- Circulation, November 3, 2010 supplement, Section 8: Acute Cardiac Life Support
- Circulation, November 3, 2010 supplement, Section 9: Post Resuscitation Care