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InterprofessionalTeamCommunicationAdult Acute Care Simulation Set‐UpandCurriculumGuide

InterprofessionalTeamCommunicationSimulationSet‐UpandCurriculumGuide........................1

TableofContents............................................................................................................................................................1

GettingStarted.................................................................................................................................................................3

ExampleHalf‐dayAgenda...........................................................................................................................................5

FacultyRequirements..................................................................................................................................................6

CourseName/DesignGroupInfo............................................................................................................................6

Debriefing..........................................................................................................................................................................7

TeamSTEPPSDebrief#1–100LevelSkills.......................................................................................................9

TeamSTEPPSDebrief#2–200LevelSkills....................................................................................................11

TeamSTEPPS/TeamSkillsDebrief#3–300LevelSkills..........................................................................13

TeamSTEPPSGlossary..............................................................................................................................................14

ClinicalScenario:DyspneainaHospitalizedPatient...................................................................................15

Overview...........................................................................................................................................................15

Timeline............................................................................................................................................................16

ScenarioParticipants..................................................................................................................................16

ClinicalOverview..........................................................................................................................................17

IntroductiontoSimulator.........................................................................................................................19

DebriefingTips..............................................................................................................................................21

MedicalTeamHandoffSheet...................................................................................................................22

NursingHandoffSheet................................................................................................................................23

PhilBrown:AdmitHistoryandPhysical............................................................................................24

PhilBrown:InformationforActorPortrayingPhil.......................................................................26

SimulationScenarioRequirementsandEquipment.....................................................................28

Storyboard.......................................................................................................................................................30

DataandResults............................................................................................................................................34

ClinicalScenario:APostoperativePatientwithTachycardia..................................................................36

Overview...........................................................................................................................................................36

Timeline............................................................................................................................................................37


ClinicalManagementofUnstableSVTandVT.................................................................................39

IntroductiontoSimulatorandScenario.............................................................................................40

DebriefingTips..............................................................................................................................................42

MedicalTeamHandoffSheet...................................................................................................................43

InterprofessionalTeamCommunicationSimulationSet‐upandCurriculumGuide


NursingHandoffSheet................................................................................................................................43

SurgicalClinicHistoryandPhysicalforPaulSmith.......................................................................44

Equipment.......................................................................................................................................................45

Storyboard.......................................................................................................................................................48

DataandResults............................................................................................................................................51

ClinicalScenario:ATeenagerwithAsthma.....................................................................................................55

Overview...........................................................................................................................................................55

Timeline............................................................................................................................................................56


ClinicalOverviewofAsthmaExacerbation.......................................................................................58

IntroductiontoSimulatorandScenario.............................................................................................59

DebriefingTips..............................................................................................................................................61

Micah:HistoryandPhysical.....................................................................................................................62

ERTriageSheet..............................................................................................................................................62

InformationforSimulationTechVoicingMicah.............................................................................63

InformationforActorPlayingMicah’sGrandma............................................................................65

EquipmentandSupplies............................................................................................................................66

PediatricPulmonaryClinicNote............................................................................................................68

Storyboard.......................................................................................................................................................70

PatientLabsandStudies............................................................................................................................75



GettingStarted

Purpose:InterprofessionalTeamCommunicationSimulationSet‐upandCurriculumGuide

Thecontentinthisset‐upguidewasdevelopedbytheMacygrantteamattheUniversityofWashington,whowerefundedin2008todevelopandintegrateinterprofessionalteamtrainingintoexistingcurriculumintheHealthSciencesschoolsofMedicine,Nursing,PharmacyandthePhysicianAssistantProgram.

TheinstructionsinthisguideareforLEADINSTRUCTORSsettingupinterprofessionalteamtrainingusingsimulationasthevectorbywhichhealthsciencesstudentscanlearntogethertodevelopandimprovebasic,intermediateandmoreadvancedlevelsofcommunicationskills.TheMacyteamusedTeamStrategiesandToolstoEnhancePerformanceandPatientSafety(TeamSTEPPS)asaframeworkfortheteamcommunicationtraining(seefigure1).

Thefourtrainableteamworkskills/competenciesdescribedinthemodelinclude:1)leadership;2)situationmonitoring;3)mutualsupport;and4)communication.Ahighlyfunctioningteamthatmastersthesecompetenciescanattainthreepossibleteamworkoutcomes:1)performance;2)knowledge;and3)attitudes.

Furtherreading:http://teamstepps.ahrq.gov/teamsteppslogo.htm

Thecontentwaspilotedin2010withagroupof50studentsandthenrolledouttoalargergroupof300+studentsin2011.

ThisguideprovidesthecontentandthestructureusedbytheMacygrantteamtoset‐upandruntheirsimulationscenarios.

Organizationofcontent

Thisguideisorganizedasfollows:

ExampleHalf‐DaySimulationSessionAgenda:UsedbytheMacyGrantTeamwhenconductingtheirteamcommunicationtraining.Dependingongroupsize,simulationscanberunsimultaneouslyorasaprogressiveseriesofsimulations.

FacultyRequirements:ItisidealifatleastoneofthefacilitatorsinthegrouphassomeknowledgeandfamiliaritywithTeamSTEPPS,instructionalbackgroundusingsimulation,andtheclinicalknowledgeneededtorunthescenario.Oftentheinstructorsmayneedtostepinandhelp



thestudentswithclinicalknowledgeinordertokeepthescenarioontracksostudentscanfocusoncommunicationskillsratherthanmedicalmanagement.

TeamSTEPPSDebriefingGuide:Includesthecommunicationobjectivestocoverinthesimulationsscenarios.Ideally,thecurriculumisdesignedtorunthreescenarios.Eachscenariobuildsoneachotherandprogressesfrombasictomoreadvancedlevelcommunicationskills.

Scenario1:BasicTeamSTEPPSskills(100level)

Scenario2:IntermediateTeamSTEPPSskills(200level)

Scenario3:AdvancedTeamSTEPPS(300level)

TeamSTEPPSGlossary.SummarizesthemostfrequentlyusedTeamSTEPPSconceptsandterminology.TheMacyGrantTeampassedouttheglossarytostudentsduringthesimulationtrainingforquickreference.

SimulationScenarios.TheMacyGrantTeamdevelopedthreesimulationscenarios.

1. ClinicalScenario:DyspneainaHospitalizedPatient2. APostoperativePatientwithTachycardia3. ATeenagerwithAsthma

Eachsimulationscenariosectionincludesthefollowing:

Overview Timeline ScenarioParticipants ClinicalOverview IntroductiontoSimulator DebriefingTips HandoffSheets(ifapplicabletoscenario) AdmitHistoryandPhysical InformationforActorsplayingtherolesofeitherpatientorfamilymember SimulationScenarioRequirementsandEquipment Storyboard DataandResults



ExampleHalf‐dayAgenda

Note:Simulationsinthissessionwererunsimultaneouslywith3separateinstructorteams

Time Activity Facilitators Materials Needed:

7:30–8:00 AM Students arrive and sign in Front desk/reception

1. Student packets andnametags

8:00–8:50 AM Icebreaker: Paper chain (link to ice‐breaker)(36 students, 6 per group) 1. As a team your goal is to create the longest chain made

out of paper links in 2 minutes, go! a. Quick debrief: What worked? Who emerged asleaders?

2. Now, same goal but you can’t use your dominant handa. How did you work together?

3. Now, you can use any resources in the room, but youcan’t talk

a. Communication and situational awareness?TeamSTEPPS Didactic Presentation Introduce check back, call out, SBAR

TeamSTEPPS facilitator

1. Paper2. Tape dispensers3. Scissors4. TeamSTEPPS Powerpoint

8:50–9:00 AM Explanation of Day, any forms used (eg, observational forms)

1. PPT slides forobservational tool

9:00–9:10 AM Break and transition into 3 groups of 6‐12 Students

9:10–9:50 AM (40 min)

Run Scenario in Groups ‐ Intro (5min) ‐ Content didactic (5min) ‐ Run scenario (15min)

o Group A (6 students) does scenarioo Group B (6 students) observes/has checklist

‐ Debrief (15min)

faculty TBD (pharmacy, medicine, nursing, PA)

1. Simulator & student/staffplaying role of familymember – SVT

2. SP – CHF (patient)3. SP – Asthma (family

member)4. TeamSTEPPS pocket guides5. Clipboards for observers

9:50–9:55 AM Walk from station 1 to station 2

9:55–10:35 AM (40 min)


o Group B does scenarioo Group A observes/has checklist

‐ Debrief (15min)


SAME AS ABOVE

10:35–10:40AM Walk from station 2 to station 3

10:40–11:20 AM (40 min)


o 6 student volunteers do scenarioo Other 6 students observes/has checklist

‐ Debrief (15min)


SAME AS ABOVE

11:20–11:30AM Transition back to big group

11:30 AM–12:00PM Wrap up Goals: 1. Reflections of students2. Descriptions of roles3. Debrief as large group

Faculty to lead big debrief

Whiteboard



FacultyRequirements

AllfacultyshouldbefamiliarwiththebasicsofTeamSTEPPS.Anarratedslidesetisavailableforreviewonthecollaborate.uw.eduwebsiteandaglossaryoftermsisincluded.LinktoTeamSTEPPSmodule.

FacultynewtosimulationcanalsoreviewanonlinemoduleIntroductiontoClinicalSimulation.

Facultyshouldalsobefamiliarwiththemanagementoftheclinicalproblemspresentedbythesimulationscenariotheywillfacilitate.Thesearefairlystraightforward,andthefacultyguideforeachscenarioincludesbackgroundinformationandcommonissuesthatarise.

CourseName/DesignGroupInfo

DevelopmentTeam: Brenda Zierler, Brian Ross, Karen McDonough, Sara Kim, LindaVorvick,PeggyOdegard,SarahShannon,SharonWilson

IntendedAudience: 4th Year Medical Students, 4th Year Nursing Students, 4th YearPharmacyStudents,2ndYearPhysicianAssistantStudents

Participants: EachModulerequires:• 2medicalstudentsplayingrolesofresidents• Aphysicianassistantplayingtheroleofamedicalprovideron

theteam• Anursingstudentplayingtheroleofabedsidenurse• Anursingstudentplayingtheroleofafloornurseavailableto

giveassistance• Apharmacystudentplayingtheroleofaninpatientpharmacist



Debriefing

LETTHETRAINEESDOMOSTOFTHETALKINGYoushouldjustbeafacilitator.Letthembringuptheissuestheyfeelneedtobediscussedandyoufinishbyfillinginwhatwasnotdiscussed.

STARTwithaClinicalDebriefStartbyaddressingclinicalmistakesorotherclinicalissuestheteambringsup.Studentswillnotbeabletofocusoncommunicationskillsiftheyhavemajorclinicalquestionsorconcerns.However,donotspendmuchtimeonthis(<5min).Scenario‐specificdebriefingtipsareincludedwitheachscenario.

SPENDTHEMAJORITYOFTHETIMEonTeamSTEPPSDebrief

Startbyaskingopenendedquestions.Asparticipantsrespond,rephrasetheirresponsesbacktothemasTeamSTEPPSskillsthatwillbecoveredinthatmodule.Ifoneoftheskillsisnotbroughtupbythegroup,youcanbringitupbrieflyatthecloseofthedebrief.

Howdiditgo?Rememberthetraineeswillbehardonthemselvessoencouragethemtofocusinitiallyonwhat

theydidwell.Mostofthefeedbacktraineesreceivethroughouttheirtrainingisnegative,sothewholetenorofthedebriefcanbeaffectedandimprovedbystartingwithpositivefeedback.

Whatdidyoudowell? Don’tletthemgotowhattheydidbadly,butwhattheydidwellfirst

Whatcouldyoudobetter? Thisquestionwilloftengetyouoffthehookfortellingthemwhattheydidbadly.Whenyouaskthisquestionthetraineeswillinvariablybringupthosemanagementareasthatyouweregoingtomention.

Whatwillyoudodifferentlynexttime? Thiswillhelpthetraineesfocusonreallymakingmeaningfulbutsimplechangesforthenexttime.

FinishbypromptingthemaboutanyspecificTeamSTEPPSskillsthatdidnotcomeoutwithopenendedquestions.(seebelow)



Theexamplesbelow*allowthefacilitatortodrawoutfromtheteamthebehaviorswhichtheythemselvesexhibitedandobserved.Thebehaviorsontheleftsideofthematrixarepositive,andtheonesontherightarenegative.Usuallytheteammembersareabletoseewhattheydidanddecideifitwas“good”or“bad”.

Element Positive Negative

EstablishtheTeam Relaxed,supportiveandapproachable

Createsatmosphereforopencommunication

Encouragesinput/feedbackfromothers

Doesnotcompetewithothers

Politeandfriendly

Appropriateuseofhumor

Tense,unapproachableandawkwardtorelateto

Blocksopencommunication

Ignoresbarriersbetweenteammembers

Competeswithother

Rudeanddismissive

Inappropriateuseofhumor

ClosedLoopCommunication Usesname,eyecontact,orpointingwhenmakingrequest

Repeatstherequest

Reportsbacktotheteamleaderwhenrequestiscompleted

Makesarequestwithoutdirectingtowardsaspecificteammember

Ignorestorepeattherequest

Failstoreportbacktotheteamleaderregardingthestatusoftherequest

*AdaptedfromTeamSTEPPSandBritishAirwaysCheck‐flightDebriefTool



TeamSTEPPSDebrief#1–100LevelSkills

1. Discuss the concepts of:A. Conducting a DebriefB. Leadership

• making requests• expecting cross-checks• task prioritization• workload balance

2. Discuss Communications SkillsA. RequestB. Cross-checkC. Check-backD. Call OutE. SBAR

TeamSTEPPS Debrief:

Ask: HowdidyoudoatincorporatingtheTeamSTEPPScommunicationskillsintoyourmanagementofthispatient?

1. Did you know who your leader was?• Someone assuming the leadership role — Point out how when someone assumed a leadership role it helped the

team plan for the times when team members were no longer able to communicate verbally. If none of thegroups had a member who did this, point out how this would have helped.

2. Did you have clearly defined team roles?• Clearly defined team roles — Ask if any of the teams had designated people who agreed to take on certain

roles. Ask if anyone was standing around wondering what to do because a clearly defined role was lacking.

3. Task Prioritization• Did the tasks get done in the correct order with emphasis on the most important first?• Did the tasks get reassigned if someone was assigned and was unable to complete the task?

4. Communication – Please discuss these specific communication skills:

Making a Request• Look at the person you are making the request to, point at the person you are making the request to

Cross-checks • Process of expecting and demanding ‘parroting’ of requests:

1. Sender initiates the message2. Receiver accepts the message and provides feedback3. Sender double-checks to ensure that the message was received

Check-backs • Process of employing closed-looped communication to ensure that information conveyed by the sender is



understood by the receiver as intended

• Checking back with the leader when the task is completed or their inability to complete the task

• Did you have the opportunity to practice closed-loop communication?

Call-Outs • Strategy used to communicate important or critical information

o informs all team members simultaneously during emergent situationso helps team members anticipate next stepso important to direct responsibility to a specific individual responsible for carrying out the task

• Reporting to the leader or team unrequested information• Reporting to the leader or team important information that was requested

SBAR: Situation, Background, Assessment, Recommendation • Often it might be better to start with the recommendation, then B, then A, then repeat R

Situation: What is going on with the patient? Background: What is the clinical background or context? Assessment: What I think the problem is? Recommendation and Request: What would I do to correct it?



TeamSTEPPSDebrief#2–200LevelSkills

1. Discuss the concepts of:A. Situational Awareness

2. Discuss Communications SkillsA. BriefsB. DebriefsC. HuddlesD. HandoffsE. SBAR

TeamSTEPPS Debrief:

As participants respond, rephrase their responses back to them as TeamSTEPPS skills. If one of the skills is not brought up after each group responds, you can bring it up later.


1.Situational Awareness — the state of knowing the current conditions affecting the team's work• Knowing the status of a particular event• Knowing the status of the team's patients• Understanding the operational issues affecting the team• Maintaining mindfulness

Conditions that Undermine Situation Awareness (SA): Failure to- a) Share information with the team b) Request information from othersc) Direct information to specific team membersd) Include patient or family in communicatione) Utilize resources fully (e.g., status board, automation)

Process of actively scanning behaviors and actions to assess elements of the situation or environment a) Fosters mutual respect and team accountabilityb) Provides safety net for team and patientc) Includes cross monitoringd) Remember, engage the patient whenever possible.

3. Team Skills

Brief• Short session (this is not a LONG) prior to the start of – the day, a clinic, a procedure, etc – to discuss

team formation; assign essential roles; establish expectations and climate; anticipate outcomes and likelycontingencies

• Should address the following questions:

Who is on the team? All members understand and agree upon the goals?



Roles and responsibilities are understood? What is our plan of care? Staff and provider’s availability throughout the shift? Workload among team members – balance and prioritized? Availability of resources?

Debrief • Informal information exchange session designed to improve team performance and effectiveness; after

action review; should follow the plan:

“What did you do or what went well”, “What could you have done better?” End with: “What should we do differently next time?”

• Should address the following questions:

Communication clear? Roles and responsibilities understood? Situation awareness maintained? Workload distribution equitable? Task assistance requested or offered? Were errors made or avoided? Availability of resources?

Huddle • Ad hoc planning, often around a single patient or event to establish or reestablish situational awareness;

reinforcing plans already in place; and assess the need to adjust the plan. Huddles can frequently happen several times during a critical event.

Hand-Off • The transfer of information (along with authority and responsibility) during transitions in care across the

continuum; to include an opportunity to ask questions, clarify, and confirm. Examples:

Shift changes Physicians transferring complete responsibility Patient transfers

SBAR: Situation, Background, Assessment, Recommendation • Often it might be better to start with the recommendation, then B, then A, then repeat R

Situation: What is going on with the patient? Background: What is the clinical background or context? Assessment: What I think the problem is? Recommendation and Request: What would I do to correct it?



TeamSTEPPS/TeamSkillsDebrief#3–300LevelSkills

Discuss the concepts of:A. Mutual support

Discuss Communications SkillsA. CUSB. 2-Challenge RuleC. DESC

TeamSTEPPS Debrief:

As participants respond, rephrase their responses back to them as TeamSTEPPS skills that will be covered in the training. If one of the skills is not brought up after each group responds, bring up that skill briefly afterward.


4. Mutual Support —• Is the essence of teamwork• Protects team members from work overload situations that may reduce effectiveness and increase the

risk of error CUS: I am Concerned!

I am Uncomfortable! This is a Safety Issue

2 Challenge Rule: • Empower any member of the team to "stop the line" if he or she senses or discovers an essential safety

breach. • This is an action never to be taken lightly, but it requires immediate cessation of the process and

resolution.

When an initial assertion is ignored… it is your responsibility to assertively voice concern at least two times to ensure it has been

heard the team member being challenged must acknowledge if the outcome is still not acceptable: take a stronger course of action and utilize supervisor or

chain of command

DESC-It (Describe, Express, Suggest, Consequences) • A constructive approach for managing and resolving conflict

D Describe the specific situation or behavior; provide concrete dataE Express how the situation makes you feel/what your concerns areS Suggest other alternatives and seek agreementC Consequences should be stated in terms of impact on established team goals; strive for consensus



TeamSTEPPSGlossary

Concept DefinitionBrief Shortplanningsessionpriortostarttodiscussteamformation;assignessential

roles;establishexpectationsandclimate;anticipateoutcomesandlikelycontingencies.

Huddle Adhocproblemsolvingplanningtoreestablishsituationawareness;reinforcingplansalreadyinplace;andassessingtheneedtoadjusttheplan.

Debrief: Informalinformationexchangesessiondesignedtoimproveteamperformanceandeffectiveness;afteractionreview.

StepProcess:

Atoolformonitoringsituationsinthedeliveryofhealthcare.ComponentsofSTEPsituationmonitoringinclude:

1) Statusofthepatient(S):patienthistory,vitalsigns,medications,physicalexam,planofcare,psychosocial2) Teammembers(T):fatigue,workload,taskperformance,skill,stress3) Environment(E):facilityinformation,administrativeinformation,humanresources,triageacuity,equipment4) Progresstowardgoal(P):statusofteam’spatients,establishedgoalsofteam,tasks/actionsofteam,planstillappropriate.

Two‐ChallengeRule:

Whenaninitialassertionisignoreditisyourresponsibilitytoassertivelyvoicetheconcernatleasttwotimestoensureithasbeenheard.Theteammemberbeingchallengedmustacknowledge.Ifoutcomeisstillnotacceptable,takeastrongercourseofactionorusechainofcommand.

CUS: Statementof:IamConcerned,IamUncomfortable,ThisisaSafetyIssue!

DESCScript: Approachtomanagingandresolvingconflict.1) Describethespecificsituationorbehavior;provideconcretedata2) Expresshowthesituationmakesyoufeel/whatyourconcernsare3) Suggestotheralternativesandseekagreement4) Consequencesshouldbestatedintermsofimpactonestablishedteamgoals;striveforconsensus

SBAR: Techniqueforcommunicatingcriticalinformationthatrequiresimmediateattentionandactionconcerningapatient’scondition:1)Situation(whatisgoingonwiththepatient?),2)Background(whatistheclinicalbackgroundorcontext?),3)Assessment(whatdoyouthinktheproblemis?),4)RecommendationandRequest(whatwouldIdotocorrectit?).

Call‐Out: Strategyusedtocommunicateimportantorcriticalinformation.E.g.TeamLeaderCallsout=“Airwaystatus?”,AssessingClinicianResponse=“Airwaystatusclear”

CheckBack: Processofemployingclosed‐loopcommunicationtoensurethatinformationconveyedbythesenderisunderstoodbythereceiverasintended.E.g.Teamleader“Give25mgBenadrylIVpush”,Clinician:“25mgBenadrylIVpush”,TeamLeader“That’scorrect”

Hand‐OffTechniques:

Transferofinformation(alongwithauthorityandresponsibility)duringtransitionsincareacrossthecontinuum;toincludeanopportunitytoaskquestions,clarify,andconfirm.



ClinicalScenario:DyspneainaHospitalizedPatientOverview

Phil Brown is a 72 year old man who passed bright red blood with a bowel movement 12 hours ago. After several more episodes, he came into the Emergency Dept. He was hemodynamically stable, and hematocrit was 24 about 10 hours ago. No active bleeding was seen with anoscopy at that time. He was admitted to the medical floor received IV fluids and 2 units of red cells, and is being prepared for a colonoscopy tomorrow. It is 2300 shift change. The primary medical team has signed out to the cross cover team, and the nurses have just changed shifts. Phil, played by a patient actor, awakes acutely short of breath.

The scenario begins with the handoff from Phil’s evening shift nurse(s), played by a faculty member, to the night nurse, played by a nursing student. The student nurse will have the opportunity to clarify and summarize the handoff communication.

When the night nurse(s) assesses Phil, he finds the patient to be acutely dyspneic. After a rapid assessment, the nurse should call the cross-cover intern or PA, communicate his concern, findings, and assessment, and make a recommendation that the patient be evaluated immediately. The cross-cover intern or PA, who has been sitting in the ‘team room’ with the other resident(s) and pharmacist should inform the rest of the team of the situation and report to the patient’s room.

The team then evaluates and manages Phil’s dyspnea. On his initial exam, he has loud crackles and difficult to hear heart sounds. A chest x-ray (if requested) is consistent with pulmonary edema. An ECG shows tachycardia. Routine labs show improvement of anemia post-transfusion, and a blood gas shows hypoxia.

If Phil receives diuretics, his symptoms quickly improve. His lungs clear, and an aortic stenosis murmur becomes easily audible if he is re-examined. The examiner has the opportunity to ‘callout’ the new finding, and the team can then revise their shared mental model.

Unbeknownst to the cross cover team, Phil had a loud murmur on admission. This was not signed out to the cross cover intern. He has unrecognized calcific aortic stenosis (which will be audible to the student using a Ventriloscope) and has developed CHF in the setting of excess volume administration.

The scenario then cuts to 7 am, when the primary intern (played by faculty) arrives back at the hospital, and the cross-cover intern or PA hands off Phil’s care and scenario ends.

Thefocusofthescenarioshouldbeonthecommunicationbetweenteammembers,notthemedicalmanagement.



Timeline

5minutes Briefreviewofthedifferentialdiagnosisandinitialworkupofdyspneainahospitalizedpatient.Thisclinicalreviewshouldallaystudentanxietyaboutclinicalmanagement,andallowthemtofocusmoreonteamcommunication.

5minutes IntroductiontotheVentriloscopeandthesimulationsetting

15minutes Runscenario

Act1,Scene1: Handofffromeveningtonightnurse(s)andinitialassessment

Act2: TeamevaluatesandmanagesPhil’sdyspnea

Act3: Philimprovesfollowingdiuretics,andanASmurmurbecomesaudible

Act4: Thecross‐coverinternorPAhandsPhil’scarebacktotheprimaryIntern

15minutes Debrief

ScenarioParticipants

Medical and/or PA students (maximum 3)A. Interncross‐coveringthepatientorPAreceivesthe‘sign‐outsheet’B. Seniorresident(s)

Nursing students (work as a team; maximum 2) A. PrimarynightnurseB. Asecondfloornurse

Pharmacy student(s) (work as a team; maximum 2) A. Medicalfloorpharmacist

Studentobservers(remainingstudentsnotassignedarole)

1Nursingfaculty–provideshandofftotheprimarynightnursetostartthescenario.Ifthingsarenotflowingsmoothly,couldalso“comebacktohelpout”.

1Medicinefaculty–actsastheprimaryintern,whoreceivessignoutfromthecross‐coverteamthefollowingmorningtoendscenariorealistically.



ClinicalOverview

Onefacultymembershouldbrieflydiscussthedifferentialdiagnosis,initialevaluation,andinitialmanagementofacutedyspneainthehospital.Thisshouldbeinteractive,andtake<5minutes.Youdonotneedtocoveralltheinformationbelow–itisincludedasarefresher.

Exampleoutline:“Acuteshortnessofbreathisacommonprobleminhospitalizedpatients,andit’stheproblemyou’llbeassessingandmanaginginthisscenario.Sayyourpatientiscomplainingofdyspnea–whatisyourinitialdifferentialdiagnosis,beforeyouhaveanyadditionalinformation?”

MajorcausesofdyspneainthehospitalCardiac

VolumeoverloadIschemiaArrhythmiaTamponade

Pulmonary:Parenchymal(AbnormalCXR)HealthcareassociatedpneumoniaAspirationARDS/AcuteLungInjuryTransfusionrelatedALIPneumothorax

Pulmonary:Airflow(OftennormalCXR)AsthmaCOPDAnaphylaxis/hypersensitivityUpperairwayobstruction(angioedema)Lowerairwaysobstruction(mucousplugging)

PulmonaryVascular(NormalCXR)PulmonaryEmbolismAirembolism

MetabolicSepsisAcidosisAnemia

“Whatwillyourinitialevaluationconsistof?”1. Focusedhistory&physical2. Reviewrecenttreatmentandprocedures3. Chestradiograph4. ECG5. Bloodgas6. Labs:Troponin,BNP,CBC,Chem,Coagindices7. ConsideradvancedimagingforPE/DVT



“Obstructivelungdisease,pulmonaryedema,healthcareassociatedpneumonia,anxiety,andpulmonaryembolismarethemostcommonreasonsforacutedyspneainthehospital.Whatwouldyourfirststepsintreatmentbeforeachofthese?”

Obstructiveairwaysdisease:Bronchodilators,steroidsNon‐invasivebi‐levelpositivepressureventilation:GoodforCOPD,lesshelpfulforasthma

CardiogenicPulmonaryEdema:TreatunderlyingischemiaorrhythmLMNOP:Lasix,Morphine,Nitrates,Oxygen,Pressure(Bi‐PAP)

HealthCareAssociatedPneumoniaBroadspectrumantibioticstocoverresistantGNRandGPCNarrowantibioticsbasedonsputumGSandculturelater

PulmonaryembolismIfhighsuspicionofPE,lowriskofbleeding.Canstartanti‐coagulationpriortodefinitiveimagingNon‐massivePE:Un‐fractionatedheparin(UFH)orLMWHMassivePE:ICUEvaluation,UFH,considertPA

AnxietyReassurancePharmacologictherapyshouldprobablybewithhelduntilotherdiagnosesexcludedwithreasonablecertainty



IntroductiontoSimulator

Onefacultymembershouldintroducethestudentstothesimulationscenarioandequipment,insomedetail.

Thisintroductionshouldcover:

A Overviewofscenario:“Inthisscenario,you’llbecaringforPhilBrown,a72yearoldmanadmittedearliertodaywithaGIbleed,whoisnowacutelyshortofbreath.Philisonamedicalfloor,inastandardhospitalroom,gettingpreppedforacolonoscopyinthemorning.Itisaboutmidnight,shortlyafterchangeofshiftforthenurses.Themedicalteamisthecross‐coverteam,whogotsign‐outonMr.Brown3hoursago.”

B Overviewofequipment“Philisapatient‐actor,inastandardhospitalbedandamonitorcapableofdisplayingsimulatedvitalsandtelemetry.Thisistheautomatedbloodpressurecuffconnectedtothemonitor.Youwillneedtocalloutarequestforcontinuousmonitoring.IfyouplacePhilontelemetry,O2Satand/orautomaticbloodpressuremonitoring,hisresultswillautomaticallydisplay.”

“Philshouldbeexaminedusingthisspecialstethoscope,calledaventriloscope.Itplaystheexamfindingswewouldlikeyoutohearandincorporateintoyourdiagnosticthinking.Besureyouhearthefindingsoraskifnoneheard.Ourpatient‐actor’sphysicalexamisactuallynormal,butwiththisventriloscopeyoumaydetectabnormalfindings.”

“Usethetelephone(orpretendtouse)tocallthemedicalteamroomtocomestattoevaluatepatient.”

“PhilhasanIVyoucaninjectmedicationsanddraw‘blood’from.Medicationsarelocatedonthispharmacycart.Syringesandphlebotomysupplieswithoutneedles,andbloodtubesarehere.Ifyouareaskedtodrawbloodoradministermeds,usethisIV.”

“Respiratoryequipment,includingnasalcannulaandanon‐rebreathermaskareattheheadofthebed.”

C Diagnostictestingandresults“Philhadrepeatlabsdrawnjustbeforethescenariostartandthenightnursehastheresults.Youcancallthelabforaddonlabs.Ifyouwantabloodgas,youshouldgothroughthemotionsofobtainingonewithoutaneedleontheABGsyringe.Resultswillbecalledoutwhenavailable.IfyouwantanECG,askforonetobedone.YouwillbehandedaprintoutoftheECG.Ifyouwantachestx‐ray,requestone.Youwillbenotifiedwhenthefilmisavailable– itwillbebroughttoyou.”

D Otheravailabledata“TheadmitH&Pisonthechartandavailablefromthenightnurse.ThecrosscoverinternorPAwillhaveasign‐outsheetincludinginformationonPhilBrown.Thenightnursewillreceiveahandoffsheetandcurrentlabresultsfromtheeveningnurse.”

E Medicationsandadministration



“Immediatelyavailablemedicationsarehereonthispharmacycart. Youwillneedtocallthepharmacyforotherrequests.IfyouneedtoadministeramedicationIV,usethisIV.Ifitisanoralmedication,itisokaytoadministeritorallytoPhil.”

F Glovesandhand‐gelareavailable

G Questions?

H Introducetheparticipants:“Wewillhavestudentsparticipateinthefollowingroles:

____medicinefloorinternorPAcrosscoveringthepatient.____seniorresident(R3).____nightshiftnurse(s).____hospitalpharmacist.____non‐participatingstudentswillbeobserversandaskedtoparticipateindebrief

Facultyalsohaveroles:___,oneofournursingfaculty,willplaytheeveningnursegivingreportonthepatient___,oneofthePAfaculty,willbetheprimaryinterngivingsign‐outsheettomedicalteamandreceivingreportaboutthepatientinthemorningtoendscenario___,allfacultywillstepintoscenariotoassistwithmedicalcontenteitherbyrequestorifneededtoguidescenariotocompletion”

I Startingthescenario:“Themedicalteam,alongwiththenightpharmacistareintheteamroom‘acrossthehall’,wheretheycanbecalledifneeded.Youmaysay:‘Medicalteam,whydon’tyouheadacrossthehallandwewillstart.’Oncethemedicalteamisoutofear‐shot,theywillbegiventhesign‐outsheet(crosscover)androlesdelineatedbythemedicalandpharmacyfaculty.ThescenariowillstartoutsideofPhil’sroom,withtheeveningnurse(faculty)handinghiscareofftothenightnurse(s).”

J Endingthescenario:At7am,primaryintern(playedbyPAfaculty)arrivesbacktoreceivereportaboutPhil’scarefromthecross‐coverinternorPA.

K Remember:TimeTimeiscompressedoverashift—Midnightto0700.



DebriefingTips

(seeTeamSTEPPSdebriefforteamcommunicationobjectives)

WhatdidyouthinkwasgoingonwithPhil?Whatsupportsthis?Whatelsewereyouconsidering?

Phildevelopspulmonaryedemaduetovolumeoverloadsecondarytoisotonicfluid,blood,andtheFleet’sprephereceived.HealsohasunrecognizedaorticstenosiswhichwasnotedonhisadmitH&Pbutnotreportedtocross‐coverteam.

Thecracklesonexamsupportthisdiagnosis,asdoeshischestx‐rayandhisresponsetolasix.Hismurmurbecomeseasiertohearashiscracklesclear,alsosupportingthediagnosisofvalvularheartdisease.

Cardiacischemiaislesslikely,givenhislackofchestpainorpressure,lackofECGchangesofischemia,andeventually,hisnormaltroponin.

Anemiafromrecurrentbleedingisareasonableconsideration,butlesslikelygivenlabresultsandthefindingsofcracklesandedemaonCXR.

Pulmonaryembolismisunlikelygivenhisveryrecenthospitalizationandx‐rayfindings,andobstructivelungdiseaseisunlikelygivennohistoryofsmokingorsimilarsymptoms,andnowheezing.

Howdidyourevaluationandmanagementgo?Commonmanagementproblemsinclude:

a. Diureticdosing.Ofcourse,thereisnosinglerightanswerhere,but5mgofIVlasixisprobablynotenoughforsomeoneinPhil’ssituation,and160mgisprobablytoomuchforsomeonewhoisdiuretic‐naïve.

b. ThinkingPhilisinworseshapethanheactuallyis(i.e.callingforanesthesiawhenheison4litersofoxygen.)Thistendstobeparticularlytruewhenthestudentshavejustperformedasimulationinvolvingaresuscitationorintubation.“Whenyoucomefromacode,youthinkthenextthingisgoingtobeacode,too.”

c. Teammayfixateoncardiacischemiaasacauseofhissymptoms.Facultymentorswillneedtoredirecttheteamifthishappens.Mayaskteamto“huddle”toredirect.



MedicalTeamHandoffSheet

(forcross‐coverinternApocket)

Patient Problemlist Medications Plan

Brown,PhilU1122334

6NE,room6214

1. ProbablelowerGIbleed,seemstohavestopped

2. Anemia,receiving2ndof2unitsPRBC

3. RepeatHctorderedat2200afterlastunitinfused

Fleet’sprepPantoprazoleAcetaminophenprn

CheckHctresultsorderedat2200–if<25,reevaluate,repeatin4hoursandconsidertransfusionCheckat0600tobesurestoolhascleared–colonoscopyplannedforAM

Wells,CarolynU9872341

6SE,room6110

1. CAP,improving2. Hypertension3. Multiplesclerosis4. Hypokalemia,withKof3.0

today

LevofloxacinLisinoprilPrazosinHCTZBeta‐interferonKCl120meqPOtoday

CheckChem7at2000–repleteKifneeded

Mitchell,StephenU7680989

6NE,room6252

DNR

1. Hepatorenalsyndrome2. Cirrhosis3. Hepaticencephalopathy4. Transplantevaluation

MidodrineOctreotideLactuloseRifaximinNadololOxycodoneprn

Doingpoorly,familyconsideringcomfortcare.Ifgettingworse(moreconfused,GIbleeding,etc)callattendingtodiscuss.

Jones,JoshU4432567

6NE,room6264

1. Cysticfibrosisexacerbation

2. Newdiagnosisofdiabetes,likelyduetopancreaticinsufficiency

Piperacillin‐tazoTMP‐SMXInhaledtobramycinInhaledDNAaseAlbuterolprnVitaminsADEKPremealinsulinlispro

Pulmonarystatusisimproving–pleaseFUonanyrecsfromPulmonaryconsultteam

Checkpre‐dinnerbloodsugarIf>180startinsulinglargine10unitsSCqhs



NursingHandoffSheet

(for11‐7RNpocket)

Patient Problemlist Medications PlanBrown,PhilU1122334

6NE,room6214

1. ProbablelowerGIbleed,seemstohavestopped

2. Anemia,receiving2ndof2unitsPRBC@1900

3. RepeatHctorderedat2200afterlastunitinfused

4. Colonoscopyprepcompleted

5. NPO6. Foleycathinplace–

output50cceveningshift

Fleet’sprep@2000

Pantoprazole40mgIVPgiven@1600

Acetaminophenprn–nonegiven

IVLR1liter@150mL/hr–2bagseveningshift

AdministerbowelprepasorderedAssisttobathroomprnBMCheckat0600tobesurestoolhasclearedcolonoscopyplannedforAMHct30post‐[email protected]‐coveringmedicalteam.

Wells,CarolynU9872341

6SE,room6110

1. CAP,improving2. Hypertension3. Multiplesclerosis4. Hypokalemia,withKof

3.0today

LevofloxacinLisinoprilPrazosinHCTZ

Chem7resultsonchartby2000–basedonresults,mayneedrepleteK.Administermedsasordered.

Mitchell,StephenU7680989

6NE,room6252

DNR

1. Hepatorenalsyndrome2. Cirrhosis3. Hepaticencephalopathy4. Transplantevaluation

MidodrineOctreotideLactuloseRifaximinNadololOxycodoneprn

Doingpoorly,familyconsideringcomfortcare.Providesupportivecareforpatientandfamily.Administermedsasordered.

Jones,JoshU4432567

6NE,room6264

1. Cysticfibrosisexacerbation

2. Newdiagnosisofdiabetes,likelyduetopancreaticinsufficiency

Piperacillin‐tazoTMP‐SMXInhaledtobramycinInhaledDNAaseAlbuterolprnVitaminsADEKPremealinsulinlispro

Arrangefordiabeteseducatortoseept/family.Bloodglucosebeforedinner.If>180startinsulinglargine10unitsSCqhsOrderlowfat,nosugardiet,caloriesperdiabeticeducatorrecommendations.



PhilBrown:AdmitHistoryandPhysical

(fordesktopcomputerorhardbackchart)

Mr.Brownisa72y.o.manwith4hoursofBRBPR(brightredbleedingperrectum).Hewokethismorningwiththeurgetodefecate,rushedtothebathroom,andpassedalargeamountofblood.Hehad4or5morebloodybowelmovementsoverthenext2hoursbeforecomingintotheED.Atthetimeofinitialevaluation,hehadhadnobloodforoveranhour.HisbloodpressurewasnormalandhisfirstHctwas28.AnoscopyintheEDwasnegativeforblood,andNGaspirateshowedbiliousfluid.After2litersofIVfluidinED,hisHctwas24.Chestx‐raynormalinED.Hewasadmittedtothemedicalfloorforfurtherevaluation.

Mr.Bdeniesabdominalpain,nausea,vomiting,chestpain,andlightheadedness.Hehadnoloosestoolsbeforetoday.HehasnopriorhistoryofGIbleedingorliverdisease.Hedenieshemorrhoids.HehasneverhadacolonoscopyorEGD.Heisnotanticoagulated,butdoesreportNSAIDuse3or4xperweek.Nofevers,chills,changeinappetiteorweightloss.Norecenttravel.Drinkscitywater,deniesunusualfood,unpasteurizedmilkorcheese,animalexposure.

PMH: Kneesurgeryin1972Pneumoniain1991

Medications: NKDAOccasionalibuprofenorASA,nomorethan4times/week

Socialhistory: Liveswithhiswife,Eileen. Retiredaccountant. LikesMariners,gardening.Nonsmoker,minimalalcohol.

ROS: Negative

Physicalexamination: VS:HR96 BP 144/66 RR16 Temp:37oC O2sat95%onRAHEENT:+conjunctivalpallor;normaloropharynxHeart:RRR,2‐3/6systolicmurmurloudestattheRUSB,possibleradiationtocarotid.NoS3orS4Lungs:clearAbdomen:normoactiveBT,soft,nontender.NoHSM.Rectalexam

normal,nostoolinvault,anoscopynegativeperED.Extremities:LEedema1+EDLab: Electrolytesnormalrange

CBCwithHgb8,Hct24,MCV91,platelets136,WBC8Stoolforentericpathogens,C.diffpendingIronstudiespending

EDChestxray:normal

Assessment: 1. OnedayhistoryofBRPBR,whichhasnowstopped.HeishemodynamicallystablebutHctis24,necessitatingadmissionfortransfusionandfurtherevaluation.Giventheacuityandseverity,themostlikelycauseofbleedingisdiverticularhemorrhage.OtherpossibilitiesareAVMsandulcers.Infectionisunlikelygiven



lackoffever,leukocytosisandexposure. Coloncancerisapossibility.

2. Heartmurmur,nopriorevaluation

Plan: 1. BRBPRa. LargeboreIVb. T&Cfor4units,transfuse2unitsPRBCsandrepeatHct;if

>28repeatinamORifclinicalevidenceofbleedingc. Colonoscopytomorrow–Fleetspreptonightd. Pantoprazole40mgIVqd(incaseUGIsource)

2. Heartmurmura. Outpatientecho

3. Fluids,electrolytesandnutritiona. LR150cc/hourb. NPOforcolonoscopyprepc. Foleycatheteruponadmission

4. Prophylaxisa. DVT–ambulatoryb. BRprivilegeswithassistance

5. Codestatus‐full



PhilBrown:InformationforActorPortrayingPhil

Initialresponsetoanyopenendedquestion(deliveredinabreathlessway):

I’mreallyshortofbreath. IwasfeelingprettygoodbeforeIwenttosleepat0930butwhenIwokeupat2330Icouldbarelymakeittothebathroom.Isatonthesideofthebedforawhilebutitjustkeepsgettingworse.

Anyothersymptoms? NO

Whatmakesitbetter? Nothing

Whatmakesitworse? Doinganything

Anythinglikethishappenbefore?

Nochestpainorchestpressure orshortnessofbreathbefore.

Whatdoyouthinkisgoingon?

Imustbehavingabadreactiontothebloodormedicationstheygaveme.

Ifaskedspecifically,youDO:

Haveageneralsenseoffatigue

Ifaskedspecifically,YOUDONOTHAVE:

Anymorebloodybowelmovements. Lastonewasat10am.Anyhistoryofheartproblemsorheartmurmur(butyoudon’tseeadoctormuch)Chestpain,tightnessorpressurewithexertionoratrestFaintingPalpitationsorasensethatyourheartisflutteringPreviouswakingupatnightfeelingshortofbreathCoughWheezingCoughingupbloodUnexplainedweightgain

Ifaskedspecifically,youalsodonothave:

SleepapneaAnyhistoryofbloodclotsordeepveinthrombosisAnyhistoryofanemiaAnyTBexposureortraveloutsideofWashingtonStateHeartburnorrefluxFeverorchillsWeightlossSwollenlymphnodesDiabetes,hypertension,orelevatedcholesterol(thatyouknowabout–youdon’tseeadoctormuch)

PersonalHistory IwasbornandraisedinSeattle,andgraduatedfromtheUW. I’vebeenmarriedfor36years,andIhave3grownchildrenand2



grandchildren. Theyalllivearoundhere,andIlovespendingtimewiththekids.

Iretiredfromaccounting5yearsago.IenjoytheMarinersandgardening.

Habits IwaswalkingaroundGreenLakeeveryday.

Idon’tsmoke,althoughIdidforafewyearsinmytwenties.Ihaveabeerortwoonweekends.Idon’tuseanycaffeine.

SexualHistory I’vebeenmarriedtomy wife,Eileenfor36years.Nootherpartners.

FamilyHistory Mymomdiedat65ofcongestiveheartfailure.Mydadis94andprettyhealthy,justgettingoninyears.Ihave3kids–theoldesthashighbloodpressuretoo,buttheothertwoarehealthy.

PastMedicalHistory I’mreallyprettyhealthy,don’tseeadoctormuch.I’vehadsomekneepainandhavetakensomeaspirinoribuprofenbutnotmuchelsewrongwithme.

Medications: Aspirinoribuprofenacoupleoftimesaweekforkneepain. Theotherdoctorsthoughtthatmighthavebroughtonthebleeding.

Allergies: none

HealthInsurance: Medicare



SimulationScenarioRequirementsandEquipment

Simulator: Patient‐actorw/ventriloscope– orhighfidelitymanikinwithlungandheartsoundtechnology

Dressedinahospitalgownandpajamabottoms,withasimulatedurinarycatheterandperipheralIV,sittingupinbedandactingshortofbreath.

Lecat’sVentriloscope(orinplaceof,highfidelitymanikinwithlungandheartsoundtechnology)MonitoravailableifrequestedtodisplaycontinuouslyBP,rhythmstripandO2Sat.

SETTING Standardhospitalequipment:Hospitalbedwithpillow,sheets,andblanketBed‐sidetableBloodpressurecuffandventriloscopestethoscopeorstethoscopeifmanikinPatientIDbandECGelectrodesHandgelExamgloves

Operational(orpretendequivalent)telephonewithpostedphonenumbersfor:

Medicalteamroom (nightnursewillcallcross‐coverinternatthis#)Lab(anyteammembercancallforresultsortoaddlabs.Mustbemanned)

Desktopcomputerwithmonitorandon‐screeniconsorprintedchartcopiesof:

History&PhysicalEDLabsEDCXR

Respiratoryequipment NasalcannulaNon‐rebreathermaskOxygenFlowmeterPulseoximeterfingerprobe

Urinarycatheterequipment FoleycatheterCollectiontubingandbagIVbagfilledwithsimulatedurine(yellowwater),connectedtocollectiontubingforreleaseofurineintourinebagifgivenLasixtosimulatediuresis

IVequipment IVpoleIVinfusionline(Y‐administrationsetforbloodinfusion)withdrainageforIVpushmedsIVbagLactatedRingersX2bagsInfusedbloodbag



Medicationsandequipment: Lasix20mg/mL 1vialclearlylabeledMorphine 1vial(1mg/ml)Nitroglycerinepaste tubeofhandcreamrelabeledDiphenhydramine25mgtabs TicTac’sAspirin325mg TicTac’sSyringeswithoutneedles 3mlX5;5mlX5;10mlX5Alcoholwipes Formedsandblooddraw

Labdrawequipment ABGkitsx3VenipuncturesetBloodtubes–purpletop,redtop

Diagnosticresultsavailableduringscenarioasorderedonseparatesheets:

Bloodgases– hypoxiabutnotdeteriorating,repeatvaluesunchangedCBC–Hct30,Hgb12forRNsign‐outsheet,Hct33,Hgb13foradditionalrequestsElectrolytes–normalvaluesandstableBUN,Creatinine‐normalvaluesandstableGlucose‐normalvaluesandstableUA‐normalvaluesandstableCardiacenzymes‐negativeandstableBNP–550ng/L(elevated)EDChestx‐ray–negativeRepeatchestx‐ray–pulmonaryedemaandcardiomegalyECG–tachycardiaonly(noischemicchanges)Anticoagulantstudies‐normalvaluesandstableAcuteLabprintout:CBC,Chem7,Cardiacenzymes,BNP(high)



Storyboard

PhilBrownisa72yearoldmanwhopassedbrightredbloodwithabowelmovement12hoursago.Afterseveralmoreepisodes,hecameintotheEmergencyRoom.Hewashemodynamicallystable,andhematocritwas24about10hoursago.Noactivebleedingwasseenwithanoscopyatthattime.HewasadmittedtothemedicalfloorreceivedIVfluidsand2unitsofredcells,andisbeingpreparedforacolonoscopytomorrow.Itis2300shiftchange.Theprimarymedicalteamhassignedouttothecrosscoverteam,andthenurseshavejustchangedshifts.Phil,playedbyapatientactor,awakesacutelyshortofbreath.

Patientisinhospitalbed,headofbedup45degreesIVpolewithY‐administrationset;LRononepoint,usedbloodbagonotherIVinonearm(hiddenline)Inhospitalgown,hospitalbottoms,foleylineoutoneleg,50ccurineinbagTelemetryelectrodesonpatientchestfor12leadECG

Bedsidetray:MedicationslistedaboveOxygennasalcannulaandrebreathermaskwithoxygenflowmeterPulseoxprobeforfingerBlooddrawingequipmentandmedicationadministrationaslistedabove

Availablepatientinformation:ChartwithH&PEDChestx‐rayEDlabwork

EveningNurse(Nursingfaculty)handoff(sheet)toNightNurse(s)Primaryintern(PAfaculty),sign‐outsheettomedicalteam

Allfacultywillstepintoscenariotoassistwithmedicalcontenteitherbyrequestorifneededtoguidescenariotocompletion.

Maysuggestteam“huddle”toredirectthescenario.



Act1:PatientAssessmentbyNurse

“Ican’tsleep”“Wenttothebathroombutbarelymadeit”“Itishardtocatchmybreath““Isatupbutitdidn’thelp”“CanIhavemoreoxygen?”

AvailableResources:Nursehaspost‐transfusionHct30

HR 110BP 148/70Sat% 98–4L/minviaNCor

rebreathermaskRR 32Wt 170

Ventriloscopeormanikinsetting:lungswithloudcrackleshalfwayup



Act2:MedicalTeamAssessment

“Wokeupshortandcouldcatchmybreath”“Alittleextrapressurefeelingonmychest““WokeupearlieracoupleoftimesSOBbutnotthisbad”“Can’treallytalk”

Rampvitalstothosebelow:HR 120BP 112/68Sat% 92‐‐96%on6LviaNCRR 32

Ventriloscopeormanikinsetting:lungswithloudcrackleshalfwayup

softASmurmur

Lasix• lotsofurine(valveopenedtourineinIVbag)

Nitropaste• BPdropsto92/48

Morphine• BPdropsto104/50

• stableBP

Aspirin• doesnothing

Diphen‐hydramine• doesnothing

FluidsfordecreaseBP

• ifIVrateincreased

“Manitisgettinghardtobreathe”

Resourcesavailable:ChestX‐ray

Cardiomegaly;pulmonaryedema

ECG–NSR;NoST‐elevationABGs–Hypoxia,unchangingOtherlabsaslisted



Act3:PhilImproves

Act4:Thecross‐coverinternorPAhandsPhil’scarebacktotheprimaryIntern

Rampvitalstothosebelow:HR 100BP 120/72Sat% 95%inon6LNRMRR 24

Ventriloscopeormanikinsetting:cracklesresolve

loudASmurmur

“ManIcanbreathebetter”

“Whathappened?”

“Howismyheart?”



DataandResults

PhilBrown



Diagnosticresultsavailableduringscenarioasorderedonseparatesheets:Bloodgases–hypoxiabutnotdeteriorating,repeatvaluesunchangedCBC–Hct30,Hgb12forRNsign‐outsheet,Hct33,Hgb13foradditionalrequestsElectrolytes–normalvaluesandstableBUN,Creatinine‐normalvaluesandstableGlucose‐normalvaluesandstableUA‐normalvaluesandstableCardiacenzymes‐negativeandstableBNP–550ng/L(elevated)EDChestx‐ray–negativeRepeatchestx‐ray–pulmonaryedemaandcardiomegalyECG–tachycardiaonly(noischemicchanges)Anticoagulantstudies–normalvaluesandstable



ClinicalScenario:APostoperativePatientwithTachycardiaOverview

PaulSmithisa55‐yearoldmanwhonowisPOD#2afteranopencolectomyforStageIIIcoloncancer.Becauseofhishistoryofcoronaryarterydiseaseandseveresleepapnea,hespentthefirstpostoperativedayintheSICU,caredforbytheSICUteam.Hehasdonewell,apartfromoneepisodeofatrialtachycardia,whichresolvedspontaneously.Becauseofthetachycardia,heistransferredtothetelemetryunitasthesurgicalteamisdoingrounds.ThejuniorresidenthasreceivedahandoffcallfromtheSurgeryfellow,buttheteamdoesnotknowMr.Smithwell.Theyarecalledbytheprimarynurse,whotellsthemthatthepatientisexperiencingarapidheartrateandhypotension.

Asthescenariobegins,thechargenurse(faculty)introducestheprimarynursetoMr.SmithandprovidesawrittenhandofffromtheSICUnurse.Theprimarynursebeginsaninitialassessment.Beforetheassessmentcanbecompleted,Mr.Smithstatesthathedidn’tsleepwellthenightbefore,nowdoesn’tfeelwellandisexperiencing“thosepalpitationsIhadlastnight.”Thebedsidemonitorrevealssupraventriculartachycardiawithaheartrateof185‐188b/m,shortnessofbreath,andlight‐headedness.Theprimarynursecallsthesurgicalteamtorelaythisinformation.Thereisafamilymemberintheroomaskingalotofquestionsandtryingtostaywiththepatient.Thenurseobtainsanotherstaffmembertostaywiththefamilymember.

Whentheteamarrives,Mr.Smithisresponsivebutcomplainsofbeinglight‐headed.Theheartrateremainsintheupper180s,andhisbloodpressureis70/50mmHg.Theteamhasaquickhuddletodetermine:1)thepresenceofsupraventriculartachycardiavs.ventriculartachycardia;2) whetherthepatientisstableorunstable;3)thecorrectACLSguidelinestouse;4)needtocallrapidresponse/codeteam.Theteamleaderordesigneemayalsoneedtoexplainwhatishappeningtotheconcernedfamilymemberatthistime.

IfPaulreceivesadenosine,hehas6secondsofasystole,thenrevertsbacktoSVT.Theteamshoulddebriefthatresponse.IfPaulreceivesaseconddoseofadenosine,hewilldeteriorateintoVF.TheteamshoulddebriefandhuddletoachieveasharedmentalmodelofVF.

WhentheteamdecidestocardiovertPaul,heshouldreceivesedationfirst(thiscanberequestorcall‐out).Thefirstcardioversionwillbeineffective.ThesecondcardioversionwillresultinVF.TheteamshoulddebriefandhuddletoachieveasharedmentalmodelofVF.

WhenPaulisinVF,theteamshouldrecognizetheneedtoswitchtodefibrillation(canbeacall‐outorrequest).Acodemustbecalled,androlesassigned(call‐outorrequestfromtheteamleader).Paulwillneedepinephrine/vasopression(call‐outorrequest).After2defibrillationsand2dosesofepinephrineorvasopressin,PaulwillconverttoasinusrhythmandtheBPwillbeabove150/90.

Theteamleader(viarequestorcall‐out)willcalltheSICUfellowtogiveahandoff(SBAR)andrequestatransfertotheSICU.TheR1willgivethehandofftothefellow,andtheprimaryRNwillgiveahandofftothereceivingRN.



Timeline

5minutes Overviewpatientandtherapyfortachycardia5minutes Introductiontosimulatorandsetting15minutes Runscenario

Act1–InitialevaluationofSVT(5minutes) HandofftoprimaryRNandRNassessespatient(1minute) PatientdevelopsSVTandissymptomatic.RNrecognizesneedforoxygen,monitor,BP

determination(1minute) RNcallsteamandperformsSBAR,teamarrives,quickevaluationandhuddle(3minutes)

Teammayreviewandrequestadditionalinformationaboutthepatientandrequest/performdiagnosticstudies,includingECGandlabs.Bytheendofthisact,theteamshouldhaveasharedmentalmodelofapostoperativepatientwithunstableSVT.Theyshouldrealizetheneedforrapidresponse/codeteamtobepresent.

Act2–ManagementofSVT(4minutes)TheteamwilleitheradministeradenosineorperformDCcardioversion.Ineithercase,thepatientwillremaininSVT,hypotensive,andcomplainingofshortnessofbreath.Asecondattemptofanytherapywillresultinventricularfibrillation(VF).

Act3–RecognitionandmanagementofVF(3minutes)TheteamwillmanageVFusingcurrentACLSguidelines(note:in2011,UWmedstudentsnolongerrequiredtotakeACLS).Afteratleastonedefibrillation,2dosesofepinephrineorvasopressin,andpossiblyonedoseoflidocaineoramiodarone,Mr.SmithwillreturntosinusrhythmwithanadequateBP.

Act4–ReturntosinusrhythmandtransferofcaretoSICU(2minutes)Sharedmentalmodelandadvancedinformationsharing.TheteamshouldcometotheconclusionthatMr.SmithisnowinsinusrhythmbutshouldreturntotheICU.TheteamleadercallstheSICUfellowandgivesahand‐offusingSBAR.TheprimarynursecallstheICUnurseandgivesahandoffusingSBAR.

Debrief–15minutes




Medicalstudentsand/orphysicianassistantstudentsA. SeniorresidentB. SurgeryteamPAC. R1D. AdditionalR1orPA(optional)

NursingstudentsA. PrimarynurseB. AnotherfloornurseC. Anothernurseneededforcode

Pharmacystudent: Teampharmacist,whoassistswithmedsduringcode

Studentobservers: remainingstudentsnotassignedarole

Pharmacyfaculty: NeededifpharmacystudentsarenotyetinclinicalrotationsNursingfaculty: Chargenurse,whostartsthescenario&mayneedtonudgeitalongMedicinefaculty: Anesthesiologistwhorespondstocall&mayneedtonudgescenarioAnyfacultyorstaff: Aconcernedfamilymemberpresentintheroom



ClinicalManagementofUnstableSVTandVT

Onefacultymembershouldbrieflydiscusstheinitialevaluationandmanagementoftachycardiainapostoperativepatient.Thisshouldbeinteractive,andtake<5minutes.

Inthisscenario,we’llbemanaginga55‐yearoldmanwhoispostopday#2afteracolectomy.Hecomplainsofpalpitations,shortnessofbreath,lightheadedness,andhasaheartrateover180b/m.Whatwouldyourinitialstepsbewhenyouseeapatientlikethis?

MajorCausesofTachycardia

Pulmonary PEPneumonia

CV Ischemia(canbe1oor2o)

Metabolic HypokalemiaHyperkalemiaHypomagnesemiaAcidosisVolumedepletion

InitialEvaluation

FocusedH&PReviewimmediateclinicaleventsDiagnostics:ECG,CXRLabs:Chem7,CBC,ABG

Themostcommonreasonsfortachycardiainapostoperativepatientareundiagnosedanemia,potassiumormagnesiumimbalance,acidosis,hypovolemia,orpulmonaryembolism.Whatwouldbeyourinitialstepsforeach?

Anemia checkH&H,administeroxygen,PC,fluids,transfuseifnecessary

Potassiumimbalance checkelectrolytes,correctwithIVpotassium

Lowmagnesium checkelectrolytes,replacewithIVmagnesium

Acidosis checkelectrolytes,ABG,considerantidysrhythmicsorcalcium,correctunderlyingcauseofacidosis

Hypovolemia checkelectrolytes,I/O,replacevolumewithisotonicfluids

PulmonaryEmbolism considerlowdoseanticoagulation,considerimagingstudiesfollowedbyeitherUFHorLMWHandICUevaluationifPEconfirmed



IntroductiontoSimulatorandScenario

Onefacultymembershouldbrieflydiscusstheinitialevaluationandmanagementoftachycardiainapostoperativepatient.Thisshouldbeinteractive,andtake<5minutes.

SPEAKLOUDfor:1)teamcommunication2)recording(ifapplicable)

A Overviewofscenario“Inthisscenario,you’llbecaringforPaulSmith,a55‐yearoldmanwhohadanopencolectomyforcoloncancer2daysago.HespendthefirstpostopdayintheSICU,becausehehasahistoryofcoronaryarterydiseaseandseveresleepapnea.Hedidwell,apartfromanepisodeofatrialtachycardiawhichspontaneouslyresolved.HeistransferredtothetelemetryunitearlyinthemorningofPOD#2,whenanotherpatientneededtheICUbed.Thefloorteamdoesnotknowthepatient,althoughtheR1receivedahandoffcallfromtheSICUfellow.Thesettingisatelemetryunit.”

B Overviewofequipment“Mr.SmithisplayedbySimMan.Breathsoundsareaudiblehereandhere,usingastandardstethoscope.Heartsoundsareaudiblehere.Theexammaychangeoverthecourseofthescenario.Thisistheautomatedbloodpressurecuffthatisconnectedtothemonitor.YouwillneedtoplaceitonSimManandverballyrequestabloodpressurereadingifyouwantonemeasuredatanytime.Whenyouconnectthetelemetryelectrodeshere,youwillseeMr.Smith’sheartrhythmcontinuously.WhenyouplacetheoximeterontoMr.Smith,youwillseetheoxygensaturationonthemonitor.”

“Medicationsarelocatedonthispharmacycart.Syringes,phlebotomyequipment,andlabtubesarehere.Ifyouareasktodrawblood,youneedtosimulatetheblooddraw.Mr.SmithhasanIVwithastopcocklocatedhere.Ifyouareaskedtoadministermedications,youwillusethisstopcock.”

“Respiratoryequipment,includinganasalcannula,non‐rebreathermask,andanAmbubagareattheheadofthebed.Thereisanoxygenflowmeterhere.”

C Diagnostictestingandresults“Iflabs,CXR,ECG,orABGsarerequested,youshouldgothroughthemotionsofobtainingone.Results(labslip,CXRresults,ECGprintout,ABGslip)willbehandedtotheteamleader.”

D Otheravailabledata“Mr.Smith’sadmissionH&Pandrecentlabsareavailableonthisclipboard.TheR1andprimarynursehavehandoffsheets.”

E Medicationsandothertreatment (Althoughwehadsyringeswithmidazolamandmorphine)“Immediatelyavailablemedicationsareonthiscart.YouwillneedtocallthepharmacytorequestanyotherSTATmedications.Ifyouneedtoadministeramedication,usethisIV.”



“IfMr.Smithrequirescardioversionordefibrillation,hereisastandarddefibrillator,whichyoushoulduseasyounormallywould.Verballycalloutthedesirednumberofjoules,butbesurethatthechargeneverexceeds20joules.”

F Questions?

G Introducetheparticipants(sometimesitworksbettertoassigncodeteamrolesatthebeginningofthescenario:Teamleader,chestcompressions,airway,defibrillatormanager,medRN,recorder)

“Wewillhave6studentsparticipate.____istheseniorresidentonthegeneralsurgeryteam,and____istheR1whogotahandofffromtheSICUfellow.____isthefulltimesurgeryPA.____isthepatient’sprimarynurseontheteleunit,and____isanothernurseavailabletohelp._____isthegeneralsurgeryteampharmacist.Facultyalsohaveroles:____,oneofournursingfaculty,willplaythechargenurse,and____,oneofourstaff,willplaytheroleofMr.Smith’sdaughter.____,oneofourmedicalfaculty,willplaytheattending.”

“Observersneedtobealertforexamplesofgoodcommunicationtechniques,orlackofcommunicationtechniquesduringthescenario.Lookforexamplesofthefollowing:

Requests Crosschecks Checkbacks Callouts SBAR

Briefs Debriefs Huddles

Mutualsupport CUS 2‐ChallengeRule DESC‐It



DebriefingTips

(seeTeamSTEPPSdebriefforteamcommunicationobjectivespages8‐15)

ClinicalDebrief

Whatwasgoingon?Whatsupportsthis?Whatelsewereconsidering?

PauldevelopsanunstableSVTfollowinganightintheSICUwherehealsohadaself‐limitingepisodeofatrialtachycardia.Presenceofshortnessofbreath,lightheadedness,andhypotensionshouldpointtheteamtousetheACLSguidelinesforunstableSVT.Paulisstillresponsive,soshouldreceivesedationpriortocardioversion.

Hypoxemiaisapossibility,buthisoxygensatsaresatisfactorywhenoxygenisadministered.

RespiratoryacidosisisrevealedinanABGobtainedwhenBMVisinplace.Hehasseveresleepapneaandcomplainedofpoorrestthenightbefore.ThereisnoindicationthatheusedhisBi‐PAPmachineintheSICU,socouldhavebeenretainingCO2.Theacidosisimprovesonceheisintubated,andhisPaCO2normalizes.

It’spossibleforPaultobeanemicfollowingcolectomy,butcurrentHctis32%.

Howdidevaluation&managementgo?

Commonmanagementproblemsinclude:1. ConcludingthatthepatientisinventriculartachycardiaratherthanSVT.Examination

oftheinitialECGshouldrevealthepresenceofclearlyvisiblePwavesinLeadsII,III.2. Administeringadenosine(ACLSguidelineforstableSVT)totreatunstableSVT.Current

ACLSguidelinesrecommendsynchronizedcardioversion.3. Omittingsedationpriortosynchronizedcardioversion.Thepatientisawakeand

responsiveandshouldbesedatedpriortocardioversion.4. Forgettingtopushthe‘sync’buttononthedefibrillatorpriortocardioversioneach

time.5. Omittinganantidysrhythmicmedicationwhentreatingventricularfibrillation.



MedicalTeamHandoffSheet

Patient ProblemList Medications Plan

Smith,PaulUxxxxxxx

5NE

1. POD#2opencolectomy2. StageIIColoncancer3. OSA–usesBiPAPat

night4. Diabetes5. CAD–IMI1yearago6. COPD7. Allergies:

a. PCNhivesb. Beestingswheeze

c. Morphine,Percocetnausea

Atenolol100mgdaily

ASA81mgdaily

Lipitor40mgdaily

Lasix20mgdaily

Metformin1000mgtwicedaily

Albuterol/atroventMDIfourtimesdaily

Advair1pufftwicedaily

Epipenprn(homemed)

1. Re‐checkCBC,chem7,ECGinam,considerK/Mgprotocol

2. SupplementalO2,BiPAP

3. Progressiveambulationandactivity

4. Progressdietwhenbowelactivityresumes

NursingHandoffSheet

Patient ProblemList Medications Plan

Smith,PaulUxxxxxxx

5NE

1. POD#2opencolectomy2. StageIIColoncancer3. OSA–usesBiPAPat

night4. Diabetes5. CAD–IMI1yearago6. COPD7. Allergies:

a. PCNhivesb. Beestingswheeze

d. Morphine,Percocetnausea

Atenolol100mgdaily

ASA81mgdaily

Lipitor40mgdaily

Lasix20mgdaily

Metformin1000mgtwicedaily

Albuterol/atroventMDIfourtimesdaily

Advair1pufftwicedaily

Epipenprn(homemed)

1. HavefamilybringinBiPAP

2. Respiratorytherapytoevaluate

3. FSBGevery6hours4. Orderlabs,ECG5. Dangleatsideofbed

thisam,uptochairthispmMonitorforreturnofbowelfunction



SurgicalClinicHistoryandPhysicalforPaulSmith

(Fordesktopcomputerorhardbackchart)

ID/CC:Mr.Smithisa55yomalewithahistoryofCAD,COPD,diabetesandsevereobstructivesleepapneascheduledforalaparoscopicpartialcolectomywithlymphnodebiopsiesforcoloncancer.Hiswork‐uptodateisnegativeformetastaticdisease.

HPI: 3weekspriortoadmission,Mr.SvisitedhisPCP,complainingofabdominalpainandconstipationforthepast1‐2weeksandbrightredbloodinthestoolX2days.Rectalexamatthatvisitshowedblood,andhewasreferredforanurgentcolonoscopy.Thisshowedastrictureinthedistalsigmoidcolon.Biopsyrevealedadenocarcinoma.AnabdominalCTshowedanareaofthickeningandnarrowinginthesameregion,butnoclearevidenceofmetastaticdisease.Hewasreferredforpartialcolectomyandlymphnodedissection.

PastMedicalHistory:

1. Coronaryarterydisease– InferiorMI1yragobutnocurrentchestpainorSOB.CathatthetimeofMIshowedcompleteocclusionofRCA,50%occlusiondistalLAD.Nointervention.EchoshowedEF52%,withinferiorhypokinesis.Otherwisenormal.

2. Hyperlipidemia3. HTNfor15yrs4. DM–5years.Controlledonmetformin,withlastHgbA1cof6.8.5. Obesity–BMIof346. SevereObstructiveSleepApnea,onCPAP7. COPD,withmostrecentFEV165%predicted.Norecentexacerbation.Has

neverrequiredsteroidsorintubation.

PastSurgicalHistory:

1. Appy,age28

Medications: 1. Atenolol100mgdaily2. ASA81mgdaily3. Lipitor40mgqd4. Lasix20mgqd5. Metformin1000mgPObid6. Albuterol/atroventMDIqid7. Advair1puffbid8. Epipen(homemed)

Allergies: PCNhivesBeeStingswheezingMostpainmeds–morphine(notmorphone),Percocet–maybenausea?

SocialHistory:

1. OccasionalETOH2. 30packyearhistory,quitsmokingafterhisMIbuthasbeensmokingabit

withthestressofhissurgery3. Marriedwiththreeteenagechildren



4. Exposures:none5. Diet/Exercise:“Notthebest–workingonit”6. Immunizations/Health/ContinuityofCare:Uptodateonimmunizations;

seesaPCPbutnotregularlyforhisOSA,diabetes,hyperlipidemia(Butheactuallyvisitedhiswife’sprimaryphysicianforcurrentproblem)

FamilyHistory:

Father(alive,80’s): HTN,HyperlipidemiaMother(alive,80’s:DMsomewhatcontrolledBrother(alive,50’s):HypertensionSister(alive,50’s):Healthy

ROS: CV:+peripheraledemaResp:+dyspneaonexertionwithclimbingoneflightofstairsAllothersnegativeexceptasperHPI–seeROSform

PhysicalExam:

ObesebutwellappearingmaninnoacutedistressVS: 148/88 76 16 97%onRAHEENT:lowhangingsoftpalate,severalmissingteeth,thickneck.Heart:RRR,normalS1andS2,noS3orS4,nomurmurLungs:clearAbd:obese,soft,nontender.Nohepatosplenomegaly.Ext:1+LEedema

Imaging: CTScanofMay27reviewedwithDr.Jonesandradiologyattending.

Lab: Normaltumormarkers,Chem7. Hct32withMCV77;otherwisenormalCBC

Assessment: 55‐year‐oldmanwithmultiplestablemedicalproblemsandanewdiagnosisofcoloncancerwithoutobviousmetastaticdisease.

Wewillattemptalaparascopicpartialcolectomy,convertingtoopenifanatomyorrespiratorystatusrequires.

Heandhiswifewerecounseledthatthisisahigherriskproceduregivenhismedicalissues.Consentsigned,surgeryscheduledforJune1.

Plan: 1. Pre‐surgeryclinicvisittomorrow2. Aspirinstopped5daysago3. Pre‐oplabs:CBC,coags,chem7,EKG4. BowelPrep:Go‐Lytely3L,pre‐openema5. NPOaftermidnight6. ORJune1

Equipment

Simulator: SimManwithsoundsystemsoitcananswerquestions



withIVline,IVbagfullComputerwithmonitor,ifrequestedwithonscreeniconsfor:

H&PAcutelabsheet

CXREKG–oldinferiorMI

RoomSetting Mannequinonhospitalbed Mannequinshouldhaveanabdominaldressing(Paul

Smithhadanopencolectomy) Hospitalgown Pillow Sheets Blanket

Attheheadofthebed non‐rebreathermask nasalcannula suctioncanister Yankeursuctiontip stethoscope Bloodpressurecuff pulseoxsensor

Codecart,andadefibrillatorontopofthecodecartStepstoolBedsideTrayChairforfamilymemberBPCuffStethoscopeVitalSignsMonitor

Respiratoryequipment Nasalcannula(alsolistedaboveinRoomSetting)Non‐Rebreathermask(alsolistedaboveinRoomSetting)OxygensourceIntubatingequipment–meshbagAmbuBagOxygenflowmeter


Phonenumbertolab(personansweringneedslabresultsandneedstoknowthattherearebloodtubesthatadditionallabscouldbeaddedto)

IVequipment IVpoleIVinfusionlineIVbag(LR)X4ABGkitX2

Medicationsandequipment:

Syringes:3mlX5;5mlX5;10mlX5

Medications



Propofol 20mlsyringesX2Pentothal 20mlsyringesX2Succinylcholine 20mlsyringeX2,10mlineachRocuronium 10mlsyringeX1Fentanyl 5mlsyringeX2Versed 5mlsyringeX2Morphine 5mlsyringe(labeled1mg/ml)X2

CodeDrugs: epiXmanyvasopressin40unitsX4lidocaineXmanyamiodarone:150mgX4;300mgX2atropineXmanycalciumXmany


H&PforMr.SmithAdditionalInfosheetforstandardizedpatientECGfromthe1stpostopdayshouldshowanoldinferiorMICXRnormal55yochestAcuteLabprintout:CBCnl,Chem7nlwithKof3.4mEq/LABGresultslipsX2

ifpatientbag‐maskventilatedduringcodeifpatientintubatedduringcode



Storyboard

PaulSmithisa55‐yearoldmanwhonowisPOD#2afteranopencolectomyforStageIIIcoloncancer.Becauseofhishistoryofcoronaryarterydiseaseandseveresleepapnea,hespentthefirstpostoperativedayintheSICU,caredforbytheSICUteam.Hehasdonewell,apartfromoneepisodeofatrialtachycardia,whichresolvedspontaneously.Becauseofthetachycardia,heistransferredtothetelemetryunitasthesurgicalteamisdoingrounds.ThejuniorresidenthasreceivedahandoffcallfromtheSurgeryfellow,buttheteamdoesnotknowMr.Smithwell.Theyarecalledbytheprimarynurse,whotellsthemthatthepatientisexperiencingarapidheartrateandhypotension.

Act#1–IntroductiontoPatientPatientisadmittedtotelemetryunitandplacedonmonitorpertheunit’sstandardofcare.

Initialvitals(frompatientchart,notonmonitoryet):

BP140/76vitalsdeterioratetoBP82/40HR102 HR185RR22 RR30Sat98%RA Sat87%RAT38.0

Patientinbedspeakingwithfamilymember

“Didn’tsleeptoowelllastnight;wokeupacoupleoftimesandfeltmyheartracing,andfeltalittlewoozy.Can’tseemtocatchmybreathwithallthiscrapI’mcoughingup”

Act#2–SupraventricularTachycardiaMonitorshouldautomaticallyshow:

VitalSigns:HR188RR34Sat88%

RNorMDwillaskforBP,whichshouldshowBP75/40

Teamshouldbecalledandhaveahuddle.Whentheyarrive

(Anxious)“Holymackerel,myheartisracingagain”

“Idon’tfeelsogood,mychestissoheavy…”

“IfeellikeI’mdying,oh,Jesus”

Iftheteamfailstosyncresultingindefibrillationratherthancardioversion,thenstayinAct2forupto2shocksthengotoAct4VentricularFibrillation.



Mayneedtopromptparticipantstosedatewithmidazolam

Shouldgiveoxygen

IfAdenosineisgiven

IfSyncCardioversion

Sats98%withoxygen,88%without

Act#3:AdenosinetoSVT

Vitals:

Rhythm–asystolefor6‐8sthenbacktoSVTHR–188BP–75/40Sat–88%

Act#3:CardioverttoSVT

Vitals:

Rhythm–SVTHR–188BP–75/40At–88%

“Wow,thosepaddlesarecold,isthisgoingtohurt?”

Onseconddoseofadenosine

Onsecondcardioversion.



Act#4:VentricularFibrillationMayneedtopromptparticipantstohavea2ndhuddle,perhapscallAttendingforassistance

Vitals:

Rhythm–VentricularFibrillationHR–0BP–0Sat–85%

After:DefibrillationAnd

atleastoneroundofVasoorEpi

And2RoundsofLidoor

Amio2nd Defibrillation

Act#5:PostV‐Fib,Ptlives!– TransfertoICU

MayneedtopromptparticipantstoperformhandofftoSICUfellow/SICURN

Rhythm– normalsinusSTdepressionMultifocalPVC’s

HR–125BP–170/100Sat–94%



DataandResults

Fromhttp://en.ecgpedia.org/



RADIOMETER ABL800 FLEX ABL825 C 09:06 9/14/2009 PATIENT REPORT CODE/Customized - S Sample # 18330

195uL

Identifications Accession No. Patient ID Patient Last Name Patient First Name

Sex Date of birth Patient note Physician Department Department (Pat.) Sampler ID Approval Note Sample age Draw time ICD9 Code Diagnostic Code Sample site Sample type T 37.0 °C PEEP Operator

Note __________________________________________________________

Blood Gas Values pH 7.100

pCO2 65.0 mmHg pO2 125 mmHg cHCO3

-((P)C 19.0 mmol/L cBase(B)C -7.0 mmol/L

Oximetry Values Hctc 36.0 %

ctHb 12.0 g/dL FO2Hb 98.1 % FCOHb 1.4 % FMetHb 0.5 % ctO2C 16.7 Vol% sO2 100.0 %

Electrolyte Values cNa+ 132 meq/L

cK+ 3.4 meq/L cCa2+ 1.11 mmol/L Metabolite Values cGlu 148 mg/dL cLac 1.99 mmol/L Temperature Corrected Values pH(T) 7.430

pCO2(T) 34.8 mmHg pO2(T) 238 mmHg

Notes c Calculated value(s)

Printed 9:18:27 09-09-14

*If Bag-Mask Ventilated



RADIOMETER ABL800 FLEX ABL825 C 09:06 9/14/2009 PATIENT REPORT CODE/Customized - S Sample # 18330

195uL

Identifications Accession No. Patient ID Patient Last Name Patient First Name

Sex Date of birth Patient note Physician Department Department (Pat.) Sampler ID Approval Note Sample age Draw time ICD9 Code Diagnostic Code Sample site Sample type T 37.0 °C PEEP Operator

Note __________________________________________________________

Blood Gas Values pH 7.230

pCO2 45.0 mmHg pO2 185 mmHg cHCO3

-((P)C 20 mmol/L cBase(B)C -4.0 mmol/L

Oximetry Values Hctc 36.0 %

ctHb 12.0 g/dL FO2Hb 98.1 % FCOHb 1.4 % FMetHb 0.5 % ctO2C 16.7 Vol% sO2 100.0 %

Electrolyte Values cNa+ 132 meq/L

cK+ 3.4 meq/L cCa2+ 1.11 mmol/L Metabolite Values cGlu 114 mg/dL cLac 1.99 mmol/L Temperature Corrected Values pH(T) 7.430

pCO2(T) 34.8 mmHg pO2(T) 238 mmHg

Notes c Calculated value(s)

Printed 9:18:27 09-09-10

*If Intubated



ClinicalScenario:ATeenagerwithAsthmaOverview

MicahStevensisa16‐yearoldwithsevere,persistentasthmawhowalksintotheEDwiththreedaysofcough,runnynoseandonedayofwheezinguncontrolledbyalbuterolMDI.Micahisportrayedbyasimulator,voicedbyaremotetechnician.

Asthescenariostarts,thetriagenurse,playedbyafacultynurse,announcesMicah’sarrivalintheER,saying“Hedoesn’tlooksogoodandtheattendingisseeinganacuteMIinroom12–youguysoughttoseehimnow.”Theteamevaluatesandtreatstheasthmaexacerbation,withmanyopportunitiesforclosedloopcommunication,informationsharing,andprovidingmutualsupport.

Unfortunately,evenwithoptimalmanagement,hebecomesprogressivelymoretiredanddevelopsarespiratoryacidosis.Heshouldbeintubated,byafacultymemberactingastheanesthesiaattending,whoperformsaRmainstemintubation.Thesimulatorlosesbreathsoundsontheleft,whichmustberecognizedbytheteam.Theanesthesiaattendingisinitiallyunwillingtoadmitthemistake,andmustbechallengedtwice.Ultimately,theerroriscorrected,MicahisstabilizedandhiscareishandedofftotheICU,anopportunitytopracticeaninterteamhandoff.

Heliveswithhiscustodialgrandmother,portrayedbyanactor,whowillarriveintheEDafterheisintubated.Theteammustdeliverthenewsofhisconditionandobtaininformationfromher.

ThereissomeconcernaboutMicah’sadherencetotherapy.Heisatypicalteenagemale,independentandnotwillingtobesupervisedinusinghismeds.HeattendshisPulmonaryClinicvisitsalone,ashisgrandmotherworks.Athislastpulmonaryclinicvisit,hisdoctorraisedconcernsaboutcompliancewithAdvair.ThepharmacystudenthastoexploreMicah’sgrandmother’sunderstandingofhisinhalerprescriptionanduse.

Thefocusofthescenarioshouldbeonthecommunicationbetweenteammembers,notthemedicalmanagement.



Timeline

5minutes Briefintroductiontoclinicalproblemandoverviewofmanagement

5minutes Introductiontosimulatorandsetting

15min Runscenario

Act1:Initialevaluationandmanagement(4minutes)Option:ThePAcanfirstevaluateandthenconsulttheR1.

Act2:ClinicalDeterioration(4minutes)

Act3:RMainstemIntubation(Rmainstem)(3‐7minutes)TheERPAoroneoftheR1s(participantsA,B,CorD)willbeaskedtocheckforbreathsounds,whicharenowabsentontheL.Ateammembershouldchallengetheanesthesiaattendinguntilcorrected.

Act4:HandofftoICU(2minutes)TheERPAoroneoftheR1s(participantsA,B,CorD)willbecalledtothephonebythefacultyRNtotalktotheICUfellow.

Act5:Discussionwithgrandma(5minutes)TheprimaryERnurse(participantE)isasked(viaoverheadspeakerorfacultyRN)togotothewaitingareatotalkwithgrandma.TheERPAoroneoftheR1s(participantA,B,CorD)willalsobeaskedtotalktograndmabyfacultyRNTheERpharmacist(participantG)willalsobepulledintothediscussionwithgrandmotherbythefacultyRN,givenconcernsovermedicationadherence,whichshouldbeexploredasallowedbytimeandthesituation.

15minutes Debrief




StudentParticipants(nametagswithnameandLARGELETTERS):3‐4 Medical/PhysicianAssistantstudents

A. R1.B. R1.C. ERPA(optional)D. AdditionalR1(optional).

1‐2 NursingstudentsE. PrimaryERnurseF. AnotherERnurse

1 PharmacystudentG. ERpharmacist

Actor:Grandmother,Katherine.

FacultyParticipants:AnursingfacultymemberwillactastheERchargenurse,startingthescenariobycallingtheERteamintothe‘room’,saying“I’vegota16yearoldkidherewithanasthmaexacerbation.IgotaCXRandcalledhisgrandma,andhadhimusehisinhaler.He’snotlookingtoogoodandtheattendingisseeinganacuteMIinroom12–you’dbettercomeseehimnow”

Amedicinefacultymemberactsastheanesthesiaattending,intubatingthepatientwhencalledtodoso.Heorsheisreluctanttoadmitandcorrectthemainstemintubation.

AnyfacultymembercanplaytheX‐raytech,whowill‘performanx‐ray’ifrequested,andpullituponcomputerfortheteamtoreview.



ClinicalOverviewofAsthmaExacerbation

OnefacultymembershouldbrieflydiscusstheinitialevaluationandmanagementofanasthmaexacerbationintheED.Thisshouldbeinteractive,andtake<5minutes.

“Inthisscenario,we’llbemanaginga16yearoldwithsevere,persistentasthmawhopresentstotheEDwithanexacerbation.Whatwouldyourinitialstepsbewhenyouseeapatientlikethis?”

Placeonmonitor,obtainIVaccess,placeO2 Begintreatment:

o Inhaledbronchodilators: Betaagonist(usuallyalbuterol)vianeborMDI,every20minutesx3 Ipratropiumprobablyalsohelpful

o Systemicsteroidsimmediatelyforsevereexacerbation,orifthereisnotapromptresponsetobronchodilatorsforalesssevereexacerbation.

Assessseverity:o Physicalexamfindingsareinsensitiveforasevereexacerbation,butifpresent,are

veryconcerning:accessorymuscleuse,inabilitytolayflat,diaphoresis.Sometimeswheezingwillgrowsofterasseverityworsens,becauselessairismoving.

o Checkpeakexpiratoryflow.<40%ofpersonalbaselinedefinesasevereexacerbation

o AnABGtoevaluateforhypercarbiaifthereisanyclinicalindication(somnolence,confusion,rapidshallowbreathing)ORlowPEFRORfailuretorespondtobronchodilators

Frequentreassessmentofresponse

“Whatwouldindicatethepatientneedstobeintubated?” <5%ofpatientsover12whovisitanERforasthmarequireintubation;however,shouldn’t

waituntilobviousrespiratoryfailuredevelops Hypoxiadespiteoxygentherapy Hypercarbia RapidshallowbreathingandobviousfatiguewithahighorevennormalCO2 Alteredmentalstatus Cardiacorrespiratoryarrest

“Howwouldweexpectateenagerwithsevere,persistentasthmatobemanagedasanoutpatient?” Highdoseinhaledsteroid Inhaledsalmeterol Inhaledalbuterolprn +/‐montelukast

“Inthiscase,thepatientisprescribedAdvair(salmeterol‐fluticasone+albuterolprn)



IntroductiontoSimulatorandScenario

Onefacultymembershouldintroducethestudentstothesimulationscenarioandequipment,insomedetail.Thisintroductionshouldcover:

SPEAKLOUDfor:1)teamcommunication2)recording(ifapplicable)

A Overviewofscenario:“Inthisscenario,you’llbecaringforMicahSteven,a16yearoldwhowalksintotheERwithanexacerbationofchronicpersistentasthma.ThesettingisanERroom,withstandardERequipmentandmedications.”

B Overviewofequipment:“Micahisasimulator.Breathsoundsareaudiblehereandhere,usingastandardstethoscope.Heartsoundsareaudiblehere.Theexammaychangeoverthecourseofthescenario.Thisistheautomatedbloodpressurecuffconnectedtothemonitor.YouwillneedtoplaceitonMicahandpress“start”andcalloutarequestforabloodpressureifyouwantonemeasuredatanytime.Otherwise,ifthecuffisonMicah,anewbloodpressurewilldisplayeveryseveralminutes.IfyouplaceMicahontelemetry,hisrhythmwillalsodisplay,andifyouplacehimonanO2satmonitorsatswilldisplay.”

“Medicationsarelocatedonthispharmacycart.Syringes,phlebotomyequipment,andbloodtubesarehere.Ifyouareaskedtodrawbloodoradministermeds,gothroughthemotions,butdon’tactuallypunctureanythingorpushanymeds.”

“Respiratoryequipment,includingnasalcannula,anonrebreathermask,andanAmbuBagareattheheadofthebed.”

C Diagnostictestingandresults“Iflabs,chestx‐ray,ECGorbloodgasarerequested,youshouldgothroughthemotionsofobtainingone.Resultswillbecalledoutwhenavailable,anddisplayedonthecomputermonitor.IfyouwantanECG,hereisthemachine.YouwillbehandedaprintoutoftheECG.Ifyouwantachestx‐ray,requestone.Youwillbenotifiedwhenthefilmisavailable–itwillbepulleduponthecomputermonitor.”

D Otheravailabledata“TheERtriagesheetisontheclipboardintheroom.Thelastpulmonaryclinicnoteisavailableonthedesktop(orinhardbackchart).

E Medicationsandadministration“Immediatelyavailablemedicationsarehereonthispharmacycart.YouwillneedtocallthepharmacytorequestanyotherSTATmedications–itisimportanttoconsultpharmacyforthedose.Ifyouneedtoadministeramedicationjustgothroughthemotions.

F Questions?

G Introducetheparticipants



“Wewillhave6studentsparticipate.____and____areinternsrotatingintheER.____isthefulltimeERPA.____isthepatient’sERnurse.____isanotherERnurseavailabletohelp.____isoneoftheERpharmacist.Threefacultyalsohaveroles:____,oneofournursingfaculty,willplaytheERchargenurse.

H Startingthescenario:“Micahhasbeentakenbacktoaroomimmediatelyfromthetriagedesk.Teammembersarehangingout,waitingforpatientstosee,whentheERchargenurseapproachesthem.”



DebriefingTips

(seeTeamSTEPPSdebriefforteamcommunicationobjectives)

WhatdidyouthinkwasgoingonwithMicah?Whatsupportsthis?Whatelsewereyouconsidering?

MicahhasinspiratoryandexpiratorywheezesthroughoutwithincreasedRR>24.Hemightneedanebulizertreatment.Ifthenebulizers'donotworkthenhemightneedanotherdrug,steroidsandorintubation.

Whatsupportsthisandwhatareyouconsidering?

Lungssounds,CXRandABGsneedtobeordered.Steroidsinadditiontonebs.IfheneedsintubationhewillneedAnesthesia,sedation,postintubationABGS,CXR.FollowupwithFamilyregardingmedicationuseandcompliance.

Howdidyourevaluationandmanagementgo?

1. DidMicahrespondtothefirstdoseofnebs?ifyesgreat!Ifnotthenheneedsanotherdoseandorsteroids

IfNo:hewillneedmoremedicationsandpotentialintubation‐@intubationtimetherecanbeanissuewithETplacementandrepositioningisneededwithrepeatCXRandABGs.

Familymember:Grandmahasinformationabouthisinhaleruse

Commonproblemsinclude:

1. noncompliancewithinhaleruse2. intubationneededduetopoorresponsetosteroidsandnebs3. PostintubationETmisplacedandneedsrepositioning4. GrandmaarrivesandwantstostaywithMicahevenduringintubationandstaffneedto

addressher. Ask:HowdidyoudecidetodealwiththeGrandmabeingintheroom?



Micah:HistoryandPhysical

HejustarrivedtotheERsonoH&Phasbeentakenyet.

ERTriageSheet



InformationforSimulationTechVoicingMicah

Initialresponsetoanyopenendedquestion

(deliveredinabreathlessway)

Ihavehadacoldforacoupleofdays,butIthinkithasgottenworsetoday.

Sincelunchithasgottenworseandworse,andIcanhardlybreathenow

Anyothersymptoms? No

Whatmakesitbetter? Nothing,infactIdon’tthinkmyinhalersareworking– IusedtheAdvair3or4timestodayanditdidn’treallyhelpatall

Whatmakesitworse? Walking,talking

Anythinglikethishappenbefore?

Ya,acoupleoftimesIthink,butnotthisbad

Whatdoyouthinkisgoingon?

It’smy‘friggin’asthma

Ifaskedspecifically,youDO:

Havearunnynose,sneezing

Ifaskedspecifically,YOUDONOTHAVE:

AnyothermedicalproblemsActive,athletic–pickyoursportandtalkaboutit

Ifaskedspecificallyaboutyourinhalers,

Youareabitvagueonhowyou’reusingthem.TheAdvairshouldbetwiceaday,andthealbuterolshouldbetheoneyouusewhenyou’reshortofbreath.Youareusingtheadvairnotsoconsistently,andsometimesyou’reusingitratherthanthealbuterolforacutesymptoms(whichisexactlythewrongthingtodo).

PersonalHistory IwasbornandraisedinSeattle,goto(yourhighschool). Iliketoplay___buthaven’tbeenabletoforacoupleofmonths‘causeI’vebeenabittoowinded.

Meandmysisterhavebeenlivingwithmygrandmaforthelastcoupleyears,becausemymom’shadtroublewithdrugs.She’sdoingbetternow,andweseealotmoreofher.Grandma’sstillworkingeventhoughsheshouldberetiredbynow.It’sbeentoughforhertotakesomuchtimeofftotakemetoappointmentsandstuff.

Habits Don’tsmokeDon’tusedrugs–Iwouldneverdothatwithwhat’shappenedwithmymomDon’tdrink



SexualHistory ‘Whatever’….

FamilyHistory Mymomishealthyexceptforthedrugsandshe’sdoingalotbetternow.Mydadisoutofthepicture.Mygrandma’shealthyandso’smysister

PastMedicalHistory I’mreallyprettyhealthy,justthisasthmathing,beeninthehospitalmaybe3timesforit.

Seemstobeworsethislastyear

Medications: 2inhalers,advairandalbuterol,vagueoncorrectuse– seeabove.

Allergies: none



InformationforActorPlayingMicah’sGrandma

Overview:A16‐yearoldwithahistoryofasthma,Micah,walksintotheEDonhiswayhomefromschool.Hehashadacoldforacoupleofdays,andaonedayhistoryofwheezinguncontrolledbyhisinhalers,andincreasingshortnessofbreath.

Hebecomesprogressivelymoreshortofbreathandiseventuallyintubated.Hehasarightmainstembronchusintubation(meaningthetubehasgoneintoofar,andtheleftlungdidn’tgetanyairforaperiodoftime.Thisisanundesirablebutfairlycommonevent.Theclinicianlistensoverbothlungsandchecksachestx‐raytoensurethetubeisintherightplace.)HeisthenstabilizedfortransfertotheICU.

TheERtriagenursecalledyouwhenMicahfirstcamein.YouarriveintheEmergencyRoom.

Atthispoint,yourgrandsonisclinicallystable.3clinicianswilltalkwithyou:

1. TheERnurse,whowillapproachyou,ensureyouareokayandtellyouabitaboutthesituation.

2. The“resident”(playedbya4thyearmedicalstudentorphysicianassistantstudent)whowilltellyouaboutMicah’sERcourseandwhattoexpect.Thisisa‘deliveringseriousnews’discussion,oftheneedforintubation,ICUadmission,andtherightmainstemintubation,whichhasnowbeencorrected.Youarecalmbutworried,andaskquestionsabouthowhehasbeentreated,howheisdoing,andwhatyoushouldexpect.Youalsoaskaboutwhatcanbedonetopreventanotherepisodeasbadasthis.

3. The“pharmacist”(playedbya4thyearpharmacystudent)whowillaskyoumoreaboutMicah’sinhalersandhowhewasusingthem.Youwanttoknowwhyhismedicationsdidn’tabortthisattack.Thepharmacistisconcernedthatincorrectuseofmedicationsmayhavecontributed(i.e.hemayhavebeenusingthelongactinginhaler(Advair)ratherthantheshortacting‘rescue’inhaler(albuterol)whenhefeltmoreshortofbreath).

Micahis16,andquiteindependent.Hehasbeenadministeringhisowninhalersforthepast3years,andbecomesannoyedifyouaskorremindhimaboutthem.Youthinkthathetakesthemasdirected,butcometothinkofit,youhaven’thadtopickuparefillontheAdvairforawhile.Youdidnotnoticeanythingunusualbeforeyouleftforworkthismorning–hewasoutofbedandintheshower

SeebelowfordetailsofMicah’smedicalhistory,fromhismostrecentPediatricPulmonaryClinicnote.



EquipmentandSupplies

Simulator: LaerdalNursingKellyorLaerdal3G Wearingahospitalgown SoundsystemtovoiceMicah FakeIVline

VitalsignsmonitorrunningSimMansoftwaretodisplaytelemetry,vitalsign

SETTING Simulatoronagurney pillow sheets blanket

Respiratoryequipmentatheadofgurney(seebelow)


AnesthesiaCriticalcarefellow

Computerwithmonitorandon‐screeniconsorprintedchartcopiesof:

LastpulmonaryclinicnoteAcutelabresultsCXRECG

Vitalsignsequipment MonitorrunningSimMansoftwareBPcuffStethoscope

Respiratoryequipment Respiratoryequipment(atheadofgurney) Oxygenflowmeter Nasalcannulae Nebulizerdevice Airoroxygensourcefornebulizer Nonrebreathermask AmbuBag Suctioncanister Yankeursuctiontip Intubatingequipmentbag,totheside

IVequipment IVpoleIVinfusionlineIVbag(LR)X4

Medicationsandequipment: SalinefishlabeledAlbuterol 3fishSalinefishlabeledAtrovent 3fishSolumedrol 1amp



Propofol 20mlsyringesX2Succinylcholine 20mlsyringeX2,10mleachRocuronium 10mlsyringeX1Fentanyl 5mlsyringeX2Versed 5mlsyringeX2

Labdrawequipment ABGkitX2Syringes:3mlX5;5mlX5;10mlX5


Papercopiesof: ECGshowingsinustachycardia CXR a.)hyperexpanded16yocxr

b.)showingRlungcollapseincaseRmainstemnotaddressed

AcuteLabprintout:CBCnl,Chem7nl ABGresultslipsX2

VerymildrespiratoryacidosisandnormalpaO2Moresevererespiratoryacidosis



PediatricPulmonaryClinicNote

(Fordesktopcomputerorpaper)

PediatricPulmonaryClinicNote,March2Thisisanoverduefollow‐upvisitforMicah,a16yearoldwithseverepersistentasthma.SincelastseeninDecember2010,hehasdonesomewhatbetter.HehasbeenseenintheEDonce,inJanuary,withanasthmaexacerbationinthesettingofaURI.HewastreatedwithIVsolumedrol,nebulizers,anddischargedwithasteroidburst.HehashadnoERvisitsorsteroidtreatmentsincethattime.

Overthecourseofthelastyear,hehashad3ERvisitsand5coursesofprednisone.Heshouldbeseenmonthly,buthasnotshowedforthelastcoupleanddidn’treschedule.Hewasbroughttotheclinicandsignedinbyhisgrandma,whohascustody,butshehadtoreturntoworkbeforehewasseen.

Hehasbeenabitmorelimitedinhisactivity.He’snolongerplayingsoccerbecausehefeelstooshortofbreath.MissedlastscheduledpulmonaryfunctiontestsinOctober,andhasn’trescheduled.

UsinghighdoseAdvair,prescribedbid,butheseemstobeusingitonceonmostdays.Usesalbuterolalmosteveryday,sometimesmorethanonce.

PMHx: Asthma,diagnosedatage7.Appendectomy,2007

Meds: Advair(salmeterol‐fluticasone)250mcgbidAlbuterolinhalerasneeded

SocialHx: Liveswithgrandma,Katherine,whoworksasanadministrativeassistantathisschool.Herworkschedulemakesittoughtoattendappointmentswithhim–sheusuallysignshiminandreturnstowork.10thgrade,doing‘okay’inschool.Nolongerplayingsoccerbutenjoyschess.Hopestoattendcollege.InsurancecoverageisMedicaid.

Physicalexamination:Overweightteenager,looksprettywell.Height175cmWeight95kgBMI31 BP124/76 HR78O2sat97%Heart:RRR,normalS1andS2,noS3orS4Lungs:scatteredexpiratorywheezing,betterafterapuffofalbuterol.Goodairmovement.Abdomen:normalExtremities:noedemaAssessment:Micahisa16yearoldwithsevere,persistentasthmaandmultipleexacerbationsoverthepastyear.He’sdonebetterinsomewaysoverthepastfewmonths,withfewerEDvisitsandsteroidbursts.However,heisnolongerabletoplaysoccerandhassomewheezingtodayonexam.I’mworriedabouthiscompliance,givenamissedappointment,missedPFTs,andlackofclarityonhowheuseshisinhalers.



Plan:1. ReeducatedMicahoninhalerusetoday.Willcontactgrandmaandseeifwecan

schedulehisnextapptatatimeshewillbeabletoattend.2. Returntoclinicin2‐3weeksforrecheck3. SchedulePFTs4. IfunimprovedwithmoreconsistentuseofAdvair,mayneedtochangeMDIsORadd

oralmonteleukast.5. DueforPneumovaxatnextvisit.ConsiderDEXA.6. Willconsidernutritionreferral.



Storyboard

Micah is a 16 year old with a long history of asthma. He had had no prior intubations but 3 ER visits in the past year and 5 courses of oral steroids. He presents to the ED with increasing wheezing and dyspnea since this morning with accompanying cough and rhinorrhea. He used his inhaler (although possibly the wrong one) multiple times during the school day and with only temporary improvement. On his way home from school he began to feel much worse and now presents for evaluation. He is immediately triaged back to a room and placed on 2 liters of oxygen. The ED team (2 residents – one identified in advance as a team leader, 2 nurses, and the Ed pharmacist) walk into the room to assume his care.

Harvey is in hospital bed: patient with nasal prongs on – O2 running at 2 liters IV pole with infusion set – LR running

Act1:InitialAssessmentinED

HR 122BP 154/62Sat% 94%on2litersRR 28Wt 135

Harveybreathsounds:diffusebilateralwheezesprolongedexpiratory

phase

cardiacexamnl

“Ican’tbreathe”

“Where’smyinhaler?”

“Dude,helpme

“Where’smygrandma–didanyonecallher?”

“CanIhavemoreoxygen?”



Act2:ClinicalDeterioration

IfteamasksforCPAPorBiPAP,machineshouldbepresentedtothem,butMicahshouldbecomeagitated,reportinghecan’tstandthemachineandinsistenttheytakeitoffhim.

Act3:Intubation:Anesthesiaattending(facultyactor)arrivespromptlyandperformsRSI.Donotneedtodemonstratesteps–simplyannouncethatitisdone.Rmainstemintubation.Breathsoundswilldisappearontheleft.

Rampvitalstothosebelow:HR 130BP 135/85Sat% rampdownto90%RR rampdownto16

shallowTV

Harveybreathsounds:lungswithloudwheezes

“Iamreallyfeelingtired”

“Ican’tkeepbreathinglikethis“

“I’mreallyscared”

“Where’smygrandma,Ineedher”

Rampvitalstothosebelowafterintubation

HR 90BP 85/40Sat% rampdownto90%RR rampdownto16

shallowTV

Harveybreathsounds:nobreathsoundsonleftwheezesonright

XTech:“xraywillbebackinabout5min”

Anesth.Attend:“Iamsurethetubeisfine”

IfMDcontinuestoreportRmainstemintub,anesthpullstube back



IfteammemberinsistsonchangingETTposition,thengotoA

IfteammemberdoesnotinsistonchangingETTposition,thengotoB

A B

WhenXraycomesbackandtubepositioncorrectedgotoAabove


HR rampto110BP 110/70Sat% rampupto99%RR manualvent

Harveybreathsounds:equalbreathsoundsbilateralwheezes


HR rampupto125BP 85/40Sat% rampdownto85%RR manualvent

Harveybreathsounds:nobreathsoundsonleftwheezesonright

XrayTech:“here’syourXray,youbetterlookatit”



Act4:HandofftoICU–R1inEDtoR1intheICU

Ifpatientnotsedatedforcontinuedintubationgoto

below

Whenpatientsedatedforcontinuedintubationgobacktoabove

Rampvitalstothosebelow:HR 100BP 110/70Sat% 99%on100%BMVRR manualvent

Harveybreathsounds:mildwheezesbilat

Rampvitalstothosebelow:HR ramp145BP 150/795Sat% 99%on100%BMVRR manualvent

Breathsounds:severewheezesbilat



Act5:Conversationwithgrandparent,whoarrivesinED

Scene:bothR1’sandteamspresent–includingpharmacist

FairlyreasonablegrandmacomesintoEDICU,isquiteupset/worriedthathergrandsonisbeingtransferredtotheICUintubated.

Shehasmanyquestionsaboutwhytheinhalerdidnotpreventthishospitalization.

PharmacistnotedthatMicahwasunclearwhichinhalerhewastouseforacutesymptoms.

Micah’sgrandmotherneedseducationonasthmatreatmentstooptimizetherapy.



PatientLabsandStudies



ArterialBloodGas#1

EDAdmission

ph: 7.46

pCO2: 31 torr

pO2: 85 torr

HCO3: 21.0 mmol/L

HCT: 40 %Hgb: 13 g/dL

cNa+ 141 meq/LcK+ 4.9 meq/LcCa2+ 1.08 meq/L

cGlu 110 mg/dL



ArterialBloodGas#2

AfterintubationFIO21.0

ph: 7.32

pCO2: 50 torr

pO2: 92 torr

HCO3: 22.0 mmol/L



cGlu 105 mg/dL



ArterialBloodGas#3

AfteradjustmentofETtubetocorrectRmainstemintubation

ph: 7.4

pCO2: 37 torr

pO2: 365 torr

HCO3: 24.0 mmol/L



cGlu 105 mg/dL

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