[Music]
Facilitator 1 (FA1): Why don't we watch another vignette?
Nurse (N): Larry? Why don't you have a seat.
My name is Nikki. I'm one of the nurses and I need to ask a few questions
about what brought you to the emergency department today.
I also need to take your blood pressure and put this thing on your finger.
Patient (P): My wife brought me to the emergency department - she's all worried.
She thinks I'm having a heart attack because I have this pain. It's not really
pain - more like a pressure - like something sitting on my chest.
N: Okay. Do you have this pressure right now?
P: Yeah
N: Now, do you have any medical problems that you see a
doctor regularly for?
P: Just my high cholesterol. But, he put me on a
medication - an anti cholesterol drug. It's much better now.
N: What were you doing when this pressure started?
P: Sleeping - woke me right up. Hasn't gone away
N: Alright. What time was that?
P: About 6:00 a.m.
N: Do you feel short of breath at all?
P: Kinda.
N: How about your stomach? Do you feel sick to your stomach?
P: A little queasy. N: A little queasy. Alright.
I need a wheelchair to triage and I'm going to be taking that last monitored bed.
Larry, how old are you? P: 52
N: 52. I have a wheelchair
and then I'm going to have you have a seat in and your wife can go ahead and
get you registered into the emergency department.
Facilitator 2 (FA2): This 52 year old male has multiple risk factors for cardiac disease: obesity,
smoking, and high cholesterol. He presents to the emergency department with chest
pressure that woke him up from sleep with nausea, shortness of breath
and diaphoresis. His heart rate (HR) is between 30 and 40 and irregular.
His respiratory rate is rapid and his blood pressure is low, 90/76. This patient is probably
having an acute MI. He needs to be seen immediately and immediate life-saving
interventions initiated. He needs IV access, fluid, pacing pads in place and
other hemodynamic interventions. He meets criteria for ESI Level 1.
FA1: Interesting case. What do you think? Do you agree? ESI Level 1?
Group: Oh, absolutely. Definitely.
Registered Nurse 2 (RN2): He may not agree.
Registered Nurse 3 (RN3): But, you know, the denial goes along with the diagnosis.
FA1: That's an excellent point. Did you notice how to diaphoretic he was?
RN2: Yes, that's one of the first things I noticed.
FA1: Yes, that across the room assessment really made you key in on that.
He had so many risk factors.
Now, why didn't I just walk him back to triage - you know - to a treatment room?
Registered Nurse 1 (RN1): Because activity increases his myocardial oxygen demand,
so you would want him to rest and get oxygen in.
FA1: That's an excellent point. We really need to do that.
RN2: He's also bradycardic and I think he was
also had hypotension. His blood pressure was low too,
so, that's another red flag.
FA2: Great, that's really the thing that makes
him a Level 1 versus a 2 - because you really don't want to make all your chest
pains Level 2. If you start making all your chest pains Level 2 and people
really aren't going to be paying attention to Level 1s. He was a Level 1
because he was bradycardic. Most chest pains the nurse can manage just
fine for the first 10-15 minutes - you put him on the monitor, you get your access,
you get your labs, you get your EKG, and you really don't need a physician at the
bedside. This patient who's that bradycardic
and hypotensive, you want to bring the doc to the bedside because you may start
doing more than those things. And the things we talked about - the pacer pads,
all that - is really good. Still, with all that, he looks pretty good
and I know I would have been surprised when I found his heart rate was 30.
I would not have originally pictured - I would have been making him a Level 1.
That was the one thing that would have made me change my mind.
RN1: Especially since he brought in that can of soda...
he was pretty active.
FA1: He had so many risk factors,
and, you know, it's true - ESI Level 1. You know, my concern would be
getting him back into that resuscitation room before he arrested.
Group: Me, too. Yeah. FA1: Good.