MEET RYAN
Ryan Evans is a 17-year-old star shooting guard on his high school basketball team.
Ryan’s dream is to play basketball at a top-rated, Division I school and although he has
been struggling on and off the court, he knows that if he works hard he can earn a
scholarship. So, he spends his free time going to extra practices, playing pickup games,
training at the gym — stronger players get more college looks — and studying to raise
his grades so he will be eligible to play.
Ryan eats, sleeps and breathes basketball and school, but finds time to help his mom
by babysitting his little sister. After his father left, his mom started working two jobs to
support them all. Ryan’s mom doesn’t have time to grocery shop, so Ryan stops by the
convenience store each morning to grab breakfast and sometimes dinner on the way
home from school. See Ryan’s food diary below.
Each year before the start of the season, Ryan is required to get a physical in order to
play for the school team and in the past his results have been normal. This year is no
different.
1.Internet Research: According to the Interactive Dietary Reference Intake
(DRI) for Healthcare Professionals calculator, Ryan should consume between
4,219 to 4,874 calories a day. Currently, Ryan is only consuming 2,639 calories a
day. Besides weight loss, how can his low-calorie diet affect him on the court and
in the classroom? Ryan could lose more weight.
2.Internet Research: According to the Mayo Clinic, an individual should
consume 45-65% of their daily calories from carbohydrates, 10-35% from protein
and 20-35% from fats. Based on Ryan’s diet, he is consuming approximately
23% from carbohydrates, 34% from protein and 48% from fat. What are the
effects of a low-carb, high-protein diet? Increased risk of heart disease Headache, Bad
breath, Weakness ,Muscle cramps, Fatigue ,Skin rash ,Constipation and diarrhea.
3.Review Ryan’s Personal Health Record: You see that Ryan is “at risk” in
several areas. What are these areas and why is he considered “at risk”?
Reflection: Ryan has a lot on his plate right now. What current stressors does
Ryan have in his life? Are these typical for someone his age? Earning scholarships
,studying for sat and act test, and making good grades. And These are typical for someone of
his age. Because they set him up for life after high school.
View Ryan’s Personal Health Record
A TRIP TO THE ED
Ryan has a big day today. He has a final exam in algebra class (one of his weakest
subjects) and a game against his school’s biggest rival where several college scouts will
be in attendance. The extra stress caused him to toss and turn all night, leaving him
exhausted this morning.
On the way to school, he quickly stops by the convenience store and grabs a popular
energy drink. He doesn’t have time to grab breakfast because he is running late and
needs to review his notes before his algebra test in first period.
The test goes well, however Ryan has started to experience some flu-like symptoms —
fatigue, lightheadedness, dizziness and nausea. The flu has been going around the
school, but he shrugs it off. He has to play in the big game; his future depends on it.
At lunch he heads to the cafeteria, grabbing another energy drink on his way. From the
cafeteria, he buys a burger patty with cheese and some peanuts, knowing that the extra
protein will help him get stronger. But, he is so nervous that he can’t eat and tosses it in
the trash. He finishes only the energy drink.
All the scouts have arrived. Ryan is anxious and nervous — jittery, restless and
extremely sweaty from the warm-up. Ryan knows he needs to play his best to secure a
scholarship, so he quickly downs one more energy drink with sport-enhancing vitamins
and minerals (he thinks it will make him more alert and provide extra energy).
Tip off — the game begins. Ryan feels unstoppable as he drains shot after shot. The
other team calls a time-out and Ryan heads to the bench. Ryan jumps to chest bump a
teammate, but as he lands his eyes blur and he faints, collapsing to the floor. Ryan’s
teammates panic, but his coach remains calm and begins CPR while a parent grabs the
AED and another calls 911. The AED is connected to Ryan. It evaluates Ryan’s
abnormal heart rhythm and signals that a shock is needed. EMTs arrive and quickly
evaluate Ryan’s vital signs and ask Ryan’s coach if there is a history of ventricular
tachycardia. Ryan’s coach is unaware of any health issues, but tells the EMTs that he
has noticed that Ryan drinks several energy drinks each day. The EMTs place Ryan on
a gurney, continue CPR with the AED and transport Ryan to the hospital. While in
transport, his heart is shocked two more times.
Ryan’s mom, who isn’t at the game because of work, is contacted and instructed to go
to the hospital immediately.
Internet Research: Ventricular tachycardia affects which body system? Define
this system.Ventricular tachycardia affects the heart's electrical system .The electrical
system in the body makes are cells specialized to conduct electrical currents in which
Electricity is required for the nervous system to send signals throughout the body and to the
brain, making it possible for us to move, think and feel.
Internet Research: Ventricular tachycardia is a type of cardiac ventricular
arrhythmia. There are four main types of arrhythmia. What are they and what
can cause them? Supraventricular Arrhythmias what causes it is A faster than normal
heart rate beginning above the heart's two lower chambers.
Ventricular Arrhythmias what causes it is abnormal heart rhythms that originate in the
bottom chambers of the heart.
Bradyarrhythmias what causes it is by Heart tissue damage related to aging and damage to
heart tissues from heart disease or heart attack..
Premature beats caused by Extra, abnormal heartbeats that begin in one of the heart's two
lower chambers.
Review the Video: Watch the video on the heart. After viewing it, explain the
purpose of the right atria, right ventricle, left atria and left ventricle.
RYAN’S ROLES
PHYSICIAN
NURSE
TECHNOLOGIST
PHARMACIST
MHSM
HEALTH COACH
SCARY WORDS TO HEAR:
SUDDEN CARDIAC ARREST
Twenty minutes after emergency care began on the basketball court, Ryan’s ED care
team is able to stabilize his heart rhythm. Once stabilized, Ryan’s physician reviews his
history, EKG, X-ray, echocardiogram and lab results including his cardiac enzyme study.
He confirms that Ryan has suffered sudden cardiac arrest as a result of ventricular
fibrillation. Ventricular fibrillation often begins as ventricular tachycardia — as the EMTs
mentioned — and in Ryan’s case, can result in sudden cardiac arrest.
The physician explains to Ryan’s mom that because of the excessive caffeine intake,
Ryan’s heart began to beat in an extremely rapid rhythm called ventricular tachycardia.
More than likely, Ryan began experiencing the tachycardia while on the court, but did
not know it because of the intensity of the game. As his heart continued to beat rapidly,
it became more disorganized and began ineffectively pumping blood to his brain.
Without enough oxygen, his brain shut down and he fainted. The physician tells Ryan’s
mom that Ryan is fortunate that his coach knew CPR and correctly utilized the onsite
AED and that the EMTs arrived quickly — these treatments saved his life.
Although Ryan’s heart rhythm is stabilized and oxygenated-blood is restored to his brain
and other vital organs, he is still in danger of brain damage. To protect his brain, the
physician suggests to Ryan’s mom that they place Ryan in a drug-induced coma and
therapeutic hypothermia for the next 24 hours. The physician explains that Ryan will be
placed in an “arctic-suit” where pads with cool water running through them are on
Ryan’s chest and thighs. This will cool his body temperature to 33 degrees Celsius (91.4
degrees Fahrenheit), which prevents the brain from overreacting and releasing harmful
cell-destroying toxins that could lead to brain damage. Because Ryan is unconscious
and under the age of 18, his mom gives permission to perform this treatment.
Internet Research: Define sudden cardiac arrest.Sudden cardiac arrest is the sudden,
unexpected loss of heart function, breathing and consciousness. Sudden cardiac arrest usually
results from an electrical disturbance in your heart that disrupts its pumping action, stopping
blood flow to the rest of your body.
Internet Research: Why is lack of oxygen to the brain — also called cerebral
hypoxia — so dangerous? Cerebral hypoxia is when the brain is completely deprived of
oxygen in which it dangerous because it can cause Feeling light-headed Intense pressure in the
brain or reddening of the face; this suggests the body is increasing blood flow to compensate
for hypoxia.Loss of consciousness.Seizures.Changes in mood, personality, or judgment.
Weakness, particularly on one side of the body.
RYAN IS ADMITTED TO THE
HOSPITAL
The following day, after a gradual rewarming from therapeutic hypothermia, Ryan is
admitted to the hospital as an inpatient. Ryan is unconscious for five days and remains
under care for an additional five days after awakening.
While in the hospital, Ryan is monitored for any signs of brain damage and cardiac
arrhythmia. Ryan has suffered short-term memory loss; he has no recollection of the
last five days or the week prior to his cardiac arrest. He is also placed on a daily
medication, Toprol-XL. The day after he awakes from the drug-induced coma, he begins
acute care physical therapy including cardiac rehabilitation. Each session lasts an
hour and leaves him physically and mentally exhausted. Ryan wonders if he has blown
his chances for a scholarship or, even worse, if he will ever be able to play basketball
again.
Additional information is added to Ryan’s inpatient chart.
After leaving the hospital, Ryan will move to a short-term care facility to continue his
recovery. At this time, it is unclear what the long-term physical or mental effects of the
cardiac event will be on Ryan. However, Ryan knows that for the rest of his life he will
need to be aware of the chance of recurring cardiac events that could lead to heart
failure. He will need to be seen regularly by a physician and practice self-care to lessen
the stress in his life and improve his mental health. Self-care is different for everyone
but may include activities such as: deep breathing, spending time with friends,
exercising, journaling, playing games, painting and listening to music.
Internet Research: The physician recommends that Ryan continue to take
Toprol-XL once he leaves the hospital. What is this medication? Toprol-XL is a
medication that can treat high blood pressure, chest pain (angina), and heart failure. This may
lower the risk of death after a heart attack.
Internet Research: Why is it given? Toprol-Xl is given to treat angina (chest pain) and
hypertension (high blood pressure).
Internet Research: The health coach provides Ryan and his mom with
information on energy drinks, their ingredients and the effect of those ingredients
on the body. Explain the side effects of each of these ingredients.
○ Caffeine-Anxiety caused people to be more alert
○ Sugar-Weight gain increase in muscle mass, fat deposits, excess fluids such as
water or other factors.
○ Ginseng-rapid heartbeat beating too fast, it may not pump blood effectively to the
rest of your body
○ Taurine-vomiting food poisoning
○ L-carnitine-Headaches pain in any region of the head
○ B Vitamins- vomiting food poisoning
View Ryan’s EHR – Inpatient
WILL RYAN BECOME ANOTHER
STATISTIC?
Ryan represents a growing population of young adults who consume too many energy
drinks, which can exacerbate conditions such as insomnia, anxiety, depression,
headaches, seizures, heart disease and arrhythmias leading to sudden cardiac arrest or
even death. Each year, the American Heart Association compiles statistics on
heart-related diseases. In 2014, approximately 350,000 people of all ages experience
out-of-hospital sudden cardiac arrest each year and nine out of 10 victims die.
Ryan’s sudden cardiac arrest was unnecessary and preventable, and he does not have
to end up as another death statistic. As a member of his health care team, you will
continue to evaluate Ryan’s progress, but a care plan will need to be in place to ensure
that his condition doesn’t worsen, reoccur or result in death. With the other members of
Ryan’s care team, use the myStation® PowerPoint presentation to develop a care plan
that reviews his hospital experience, but also provides steps for Ryan to become
healthier and possibly reverse some of the effects of his poor lifestyle choices.
In addition to Ryan’s story, the following resources may be helpful in developing the
myStation® PowerPoint presentation:
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Ryan’s Personal Health Record
Ryan’s EHR — ED Chart
Ryan’s Virtual Physical Exam
Ryan’s EHR — Inpatient Chart
Student Portal
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Below is a summary of Ryan’s EHR activity while he is in the ED. As an ED physician,
you are responsible for examining the patient, ordering tests and procedures and
diagnosing Ryan’s condition. Using his EHR, Virtual Physical Exam (VPE) and Internet
research, answer the questions and be prepared to discuss the responses with the rest
of Ryan’s health care team.
Internet Research: In the ED, advanced cardiac life support (ACLS)
continues. Ryan is hooked up to the hospital’s standard defibrillator with monitor
and is shocked for a fourth time with 200 joules. What is the purpose of
defibrillation? To reset the electrical state of the heart so that it may beat to a rhythm
controlled by its own natural pacemaker cells.
Review Ryan’s VPE: Ryan has 10 electrodes placed on his chest for a 12-lead
electrocardiogram (EKG). Explain an EKG. An EKG is a paper or digital recording of
the electrical signals in the heart. It is also called an electrocardiogram or an ECG. The EKG is
used to determine heart rate, heart rhythm and other information regarding the heart's
condition.
Review Ryan’s ED EHR: What does Ryan’s EKrG indicate? The heart rate and the heart
rhythm
Internet Research: During ACLS, you order Vasopressin and Amiodarone. What
are these medications and why are they used?
Internet Research: Ryan responds to the ACLS measures, so you order a
cardiac enzyme study, chest X-ray, non-contrast CT scan of the brain/head and
echocardiogram. What information can you gather from each of these tests?
○ Cardiac enzyme study:Cardiac enzyme studies measure the levels of enzymes and
proteins that are linked with injury of the heart muscle. These include the enzymes
creatine phosphokinase (CPK) and creatine kinase (CK), and the proteins troponin I
(TnI) and troponin T (TnT).
○ Chest X-ray:A chest X-ray is a fast and painless imaging test that uses certain
electromagnetic waves to create pictures of the structures in and around your chest.
This test can help diagnose and monitor conditions such as pneumonia, heart failure,
lung cancer, tuberculosis, sarcoidosis, and lung tissue scarring, called fibrosis.
○ Non-contrast CT scan of the head: A CT brain is ordered to look at the
structures of the brain and evaluate for the presence of pathology, such as
mass/tumor, fluid collection (such as an abcess), ischemic processes (such as a stroke).
It is particularly good for hemorrhage, trauma or fracture to the skull and for
hydrocephalus.
○ Echocardiogram:An echocardiogram (echo) is a test that uses high frequency sound
waves (ultrasound) to make pictures of your heart. The test is also called
echocardiography or diagnostic cardiac ultrasound.