Background Information This exercise is meant to simulate an “on call” situation. As an intern, you take call alone at night for the family medicine service. There are several doctors who are also on call and are always available for back-up support or questions. If necessary (when you are on call in the future as well as for this exercise) you may call for help. The group of available physicians includes your 2nd year resident, the family medicine attending, an ICU attending, and attendings from any specialty group that is needed. Nurses are also a good resource for questions. It is always ok to ask for help. When working through these scenarios, please try to respond as you would in a real-life situation. You may order tests, request more information if needed, give medications, call codes, or transfer patients. We will try to respond accordingly. Do not try to give doses or specific names for medications. It is fine to say, “Give a calcium channel blocker.” You do need to be more specific than, “Give something for blood pressure.” At the end of the scenario you will be asked to write a brief summary note. You may take notes if needed.

Patient Information You receive a call in the night from the 5th floor nurse. Mr. Smith, a 69 year old man admitted yesterday for cellulitis of the leg, is having chest pain. She quickly tells you that Mr. Smith has a history of hypertension and no known cardiac disease. What would you like to do?

Vitals Heart rate: 118 bpm Blood pressure: 120/80 Respiratory rate: 20 Temperature: 98.8

Pulse Oximetry Pulse ox: 95% on room air

Evaluate Patient General: lying on bed, holding chest. Diaphoretic. Complaining of chest pain. Cardiac: Normal heart sounds. No JVD. Respiratory: Bilateral lungs clear to auscultation. Equal breath sounds. No wheezes or crackles. Abdomen: Normal exam Extremities: No edema. Light erythema upper left leg from cellulitis (“better” per patient). Rectal: Normal. Guaiac negative.

Labs CBC: WBC 9.0, Hemoglobin 12.8, Platelets 225,000. Basic metabolic profile: Na 130, K 4.2, Cl 110, CO2 25, BUN 10, Creatinine 1.0, Glucose 98 (all normal) Troponin 8.0 (normal <0.03)

Arterial Blood Gas pH: 7.42 pCO2: 38 HCO3: 24 pulse ox: 94%

Ask 2nd Year Resident, Family Medicine Attending, Cardiologist (before patient evaluated) She says, “Evaluate the patient. Get an EKG. Call me back if you need any help.” Would you like to do anything else?

Ask 2nd Year Resident, Family Med Ask 2nd Year Resident, Family Med. Attending, or Cardiologist (before EKG or enzymes ordered) She says, “get an EKG and order enzymes, make sure he’s stable. Call me back if you need any help.” Would you like to do anything else?

Ask 2nd Year Resident (after EKG or enzymes interpreted) She says, “Sounds like it might be cardiac. Make sure he’s stable. Treat his pain. Oh yeah, give him an aspirin if you think he needs it. I’ll come in to the hospital.” (She’s now unavailable as she’s driving in)

Call Cardiologist (EKG ordered, but not interpreted correctly) He says, “Fax me the EKG.” He faxes back, “This patient is having an acute anterior MI. Reevaluate the patient and start treatment. I’ll come in. Call me back if you need me.”

Call Family Medicine Attending (after EKG interpreted and patient evaluated) He says, “Give him an aspirin, anti-platelet agent, and start heparin and a beta blocker. Start a Nitroglycerin drip for his pain (watch his blood pressure). Call cardiology and notify them also.”

Call Cardiologist (after EKG interpreted and patient evaluated) He says, “Give him an aspirin, start heparin, an anti-platelet agent, and a beta blocker, start a Nitroglycerin drip for his pain (watch his blood pressure). I’m on my way in!”

Start Heparin drip Patient appears a bit more stable. Would you like to do anything else?

Give IV fluids Patient appears a bit more stable. Would you like to do anything else?

Give an aspirin Patient appears a bit more stable. Would you like to do anything else?

Give Anti-platelet agents Patient appears a bit more stable. Would you like to do anything else?

Start a beta blocker Patient appears a bit more stable. Would you like to do anything else?

Give Nitroglycerin Patient’s pain decreases. Would you like to do anything else?

Give Morphine Patient’s pain decreases. Would you like to do anything else?

Oxygen Oxygen is started by nasal cannula. Pulse ox is 98% on 2L of oxygen.

Transfer to ICU (before notifying cardiologist) Patient is transferred quickly. The ICU doctor is off the floor, assisting with a code. Would you like to do anything else?

Transfer to ICU (after notifying cardiologist) Patient is transferred quickly. The cardiologist arrives, starts thrombolytics and patient is immediately transferred to the cath lab. Five days later patient is discharged in stable condition.

Ask nurse for help Nurse says, “Call _____________” Second year resident Attending Cardiologist (can fax EKG to read) ICU Attending

One hour later the nurse calls, saying she is still nervous about the patient. “He looks even worse than he did earlier.” What would you like to do?

Call a Code The code team arrives and realizes that the patient is awake and responsive, complaining of chest pain. One of the residents recommends that you call the cardiologist.