Saturday, February 18, 2012

A Date with Mr. Smith

I had a date with Mr. Smith today. But he would not be going anywhere.

Mr. Smith laid on the bed surrounded by his nurses. The Normal Saline IV on his left arm was just to keep the vein open. His eyes stared unseeingly but his eyes blinked. A thin sheen of moisture on his waxy face suggested diaphoresis. The nurse looked at the cardiac monitor and her face showed concern at the tachycardia and the hypotension.

“His radial pulse is bounding. Heart rate is 126, BP 90/70″, she reported to the other nurses at the bedside.

Mr. Smith’s lips did not move but a disembodied voice startled the other nurse who was listening at his lungs. He said, “ It feels like an elephant is sitting on my chest”.

Nurse 1 changed Mr. Smith’s nasal cannula to a 100% non-rebreather mask to raise his oxygen saturation from the 92% displayed on the cardiac monitor. She raised the head of the bed and asked the patient care technician to do a stat EKG. The nurse looked around and caught my eyes. I knew what she wanted so I reassured her that I called for the doctor already.

Nurse 2 reported that he heard rales 1/3 up bilaterally. Both nurses exchanged a worried look. The outgoing nurse tried to finish her report. “Mr. Smith just came to the ED one hour ago complaining of shortness of breath for several days exacerbated by walking up the stairs. This morning, he woke up feeling he was drowning with his secretions. Chest x-ray showed bilateral pneumonia. We got him his Lasix 40 mg already.”

The foley catheter bag on the side of the bed was draining with 300 ml of amber-colored urine. Lasix urine, I thought.

Nurse 1 said, “Uh-oh, his BP is going down. Where’s the doctor ?”.

The patient stopped talking. Nurse 1 darted a look behind her at the unexpected turn of events. “Mr. Smith, are you okay?” . The cardiac monitor displayed ventricular fibrillation. There was just a second hesitation when the nurses processed what they were seeing on the machine, but soon their ACLS training went into gear.

Nurse 2 felt for the carotid pulse. “No pulse”. The outgoing nurse stopped her report, and started her compressions. But she had to stop for a few seconds as she grabbed a stepstool from the other side of the room.

There was a slight tremor in the Nurse 2′s voice but he pulled himself together and, after making sure that everyone cleared off the patient, quickly delivered a defibrillation shock on the patient. He reported later that it felt empowering to press on the paddles and deliver the shock that his patient needed.

“Still no pulse”. The other two nurses resumed CPR; one nurse doing compression on Mr. Smith, while the other nurse pushed air through the ambubag. Thirty compressions, two breaths.

The doctor came in and the first nurse gave a quick report. Dr. Morris had not even given the order yet, but the nurse handed her an Epinephrine, clearly anticipating the first drug on the ACLS algorithm. Dr. Morris was a second-year ED resident and this is her first code. The attending physician was busy with another code in the other room.

Dr. Morris took a deep breath, but she knew that the other nurses had worked in the ED for a long time. The code continued with the veteran nurses basically suggesting the next step to the doctor who just happily agreed with all their suggestions.

The patient was their focus and the team members worked as hard as they’ve always done. After the initial confusion, the team had settled down and continued with the ventricular fibrillation algorithm.

After another cycle of defibrillation, compressions, and drugs, a pulse check revealed a strong pulse. The cardiac monitor showed Normal Sinus Rhythm. The blood pressure was still low, so upon the nurse’s suggestion, Dr. Morris ordered a Dopamine drip.

Mr. Smith opened his eyes and spoke again, “Hello there”. Everybody smiled. And applauded that they survived Simulation.

End of Simulation. Start of Debriefing.

I stepped behind the one-way mirror of the control room. My students stood around Mr. Smith in the room that was outfitted like a state-of-the-art ED room. I led the group into the Debriefing Room.

That was my date with Mr. Smith. He’s our new hi-fidelity human patient simulator, our newest toy in nursing education.

Mr. Smith is the high-fidelity sim-manikin that we’re using in my hospital. He can pretty much do anything else, well, almost anything. He’s an interactive manikin specifically designed for training in anesthesia, respiratory and critical care. He is capable of realistic physiologic responses, including respiration, pulses, heart sounds, breath sounds, urinary output, and pupil reaction.

Simulation training in nursing education had established itself as an effective teaching strategy. It allows the students to be involved in patient care experiences, with the use of simulation manikins, where they can practice clinical skills and demonstrate their critical thinking abilities in a safe environment. Simulation learning also permits learning team work and good communication among the different disciplines who are involved in patient care.

The Debriefing is where we reflect on the just-concluded simulated case scenario. The students reflect on their feelings, and their performance during the scenario. I reviewed with them key points in the scenario, putting emphasis on successful performance of expected skills.

The nurses enjoyed their first date with Mr. Smith. I told them that we will be introducing more case scenarios with Mr. Smith. COOL.
Key Features:
1. Pupils that automatically dilate and constrict in response to light
2. Thumb twitch in response to a peripheral nerve stimulator
3. Automatic recognition and response to administered drugs and drug dosages
4. Variable lung compliance and airways resistance
5. Automatic response to needle decompression of a tension pneumothorax, chest tube drainage and pericardiocentesis
6. Automatic control of urine output