Week 13

Reflection:

Using the Gibb’s Reflective Model I will reflect on the twelfth Lab session we had for this semester. It took place on the 25th of November.

Description: This week we had the insertion of an advanced airway OSCE. I followed the steps in the OSCE marking sheet and answered my examiner’s questions. I passed this OSCE. Later we practiced auscultating different breath sounds on the mannequin. Mine was diminished in the rt lung and normal in the lt. But I got it wrong. After that my colleagues and I prepared our jumpbag for another epic scenario. This time we had everything in the bag so as not to keep running to the store during the scenario. After this my teacher invited my dad to watch me perform an approach to a cardiac patient. I asked the patient about their pain using PQRST and took his vital signs. I gave him nitrates for his chest pain. An EMT came at this point. The patient was still in pain, so I ordered the EMT to set up an IV and administer Morphine. Suddenly on the ECG the rhythm changed from sinus tachycardia to VF. I started compressions and ordered the EMT to attach the pads of the defibb. Once the pads were on, she charged the defibb to 200 J, since its biphasic, and shocked the patient, after ensuring I was clear of the patient.  This lasted two cycles then the patient had a  NSR. I checked for pulse, and it was there. At this point I called the hospital and handed the case over to them and initiated transport. Later on in the session we had another epic OSCE.  My colleagues and I alternated roles between compressing, inserting the igel and ventilating the patient, and setting up an IV to administer Morphine. However, our communication was really bad.

Feelings: At first I felt a little nervous about the OSCE, but once I passed I felt really good. I felt nervous during my scenario since my dad was there but that also slowly subsided and I regained my confidence. Finally, the epic scenario was great and it felt so good to do even better than last week, except for the communication.

Evaluation: The OSCE was a really good experience. The scenario started as a bad experience but once I got through it I realized it was really good. The epic OSCE was a great time. My colleagues and I’s communication with each other was bad but other than that we did really well. Not recognizing the breath sounds was a bit of a setback for me.

Analysis: I shouldn’t have felt nervous during my scenario since I knew what I had to do. Being nervous only limited my abilities.

Conclusion: I could have remained calm and focused to perform the best I can. Also, I could have talked with my team and agreed with them on what each of our roles was going to be. This is to avoid unnecessary chaos and confusion. Also, when auscultating the chest I should take my time to listen to the patient’s breathing to correctly recognize the breath sounds.

Action Plan: I plan to listen to different breath sounds online to be able to recognize  them next time. Also, I plan to remind myself to stay calm and composed no matter what to provide the best possible care. Finally, I will practice my communication skills.

Domain Knowledge:

Aneurysm is a sac formed by the localized dilatation of the wall of an artery, a vein or the heart. Can be fusiform or saccular. 

Risk factors: HT, atherosclerosis, genetic.

Aortic aneurysm presentation depends on site of dissection. Presents with pain to the back, hypotension, pallor, cool, mottling distally, ripping/tearing sensation, impending doom, variable BP. Presentation similar to ischemic cardiac arrest pain.

Management: Do not give fluid (will increase afterload, causing further damage at aneurysm), or make the pt. walk or loosen their belt. 

Pericarditis caused by unknown, bacterial infection, viruses, parasites, post MI, heart surgery, rheumatic fever, rheumatoid arthritis, AIDS. Diagnosis is often recurrent, severe chest pain(sharp, severe, constant), exacerbated by lying down and inspiration, relieved by leaning forward. Also, diffuse ST elevation in all leads. (Pericarditis all around the heart)

Hyperkalemia: Serum K>5.5mEq/l. Increased K causes major changes to ECG.

6.5-7.5 mEq.L: tall peaked Twaves, short QT interval, prolonged PR interval

7.5-8mEq/L: QRS widening and flattening of P wave

10-12 mEq/L: Widened QRS and tall T wave

Hypothermia produces osborn waves when T<32C. Bradycardia and pulseless in severe cases.

LBBB most commonly due to blockage of anterior fascicle of left BB.

Inspiration, palpation,movement, and coughing can produce chest pain.

Takotsubo majority are women who suffer this (cause women are too emotional). Often occurs after bad news. Presents as HF due to impaired LV function. Angiogram shows coronary arteries not blocked so can't be LVF. Normally resolves in up to  months.

Enquiry and Research:

A heart suffering Takotsubo resembles a Japanese pot used to collect an octopus called takotsubo (Sharkey et al., 2011).

Takotsubo presents as an AMI (Golabchi &Sarrafzadegan, 2011).

References

Golabchi, A., & Sarrafzadegan, N. (2011). Takotsubo cardiomyopathy or broken heart syndrome: A review article. Journal of Research in Medical Sciences, 16(3), 340-345. 

Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3214344/

Sharkey, S.W., Lesser,J.R.,& Maron, B.J. (2011). Takotsubo (Stress) Cardiomyopathy. Circulation, 124, e460-e462. doi: 10.1161/CIRCULATIONAHA.111.052662