California Simulation Alliance (CSA) Simulation Scenario .

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California Simulation Alliance (CSA)Simulation Scenario TemplateThe California Simulation Alliance (CSA) is comprised of simulation users from all disciplinesfrom throughout the state. Several regional collaboratives have formed totaling 7 as of March,2011: The Rural North Area Simulation Collaborative (RNASC), the Capital Area SimulationCollaborative (CASC), the Bay Area Simulation Collaborative (BASC), the Central ValleySimulation Collaborative (CVSC, the Southern California Simulation Collaborative (SCSC), theInland Empire Simulation Collaborative (IESC), and the San Diego Simulation Collaborative(SDSC). The CINHC, a non-profit organization focused on workforce development in healthcareprovides leadership for the CSA.The purpose of the California Simulation Alliance (CSA) is to become a cohesive voice forsimulation in healthcare education in the state, to provide for inter-organizational research onsimulation, to disseminate information to stakeholders, to create a common language forsimulation, and to provide simulation educational courses. The goals of the alliance will includeproviding a home within the CINHC for best practice identification, information sharing, facultydevelopment, equipment/vendor pricing agreements, scenario development, sharing andpartnership models. More information can be found on the CSA website atwww.californiasimulationalliance.orgAll scenarios have been validated by subject matter experts, pilot tested and approved by theCSA before they were published online. All scenarios are the property of the CINHC/CSA. Thewriters have agreed to release authorship and waive any and all of their individual intellectualproperty (I.P.) rights surrounding all scenarios. I.P release forms can be found atwww.bayareanrc.org/rsc and click documents. (Please send signed I.P. release forms to KT atkt@cinhc.org)CSA REV template (12/15/08; 5/09; 12/09; 4/11)

TABLE OF CONTENTSSECTION ISCENARIO OVERVIEWA. TitleB. SummaryC. Evidence BaseSECTION IICURRICULUM INTEGRATIONA. Learning Objectives1. Primary2. Secondary3. Critical ElementsB. Pre-scenario learner activitiesSECTION III SCENARIO SCRIPTA.B.C.D.E.F.G.Case SummaryKey Contextual DetailsScenario CastPatient/Client ProfileBaseline patient/client simulator stateEnvironment / equipment / essential propsCase flow /triggers / scenario developmentSECTION IV APPENDICESA. Health Care Provider OrdersB. Digital Images of Manikin / MilieuC. Debriefing GuideCSA REV template (12/15/08; 5/09; 12/09; 1 2015)ii

1SECTION I: SCENARIO OVERVIEWScenario Title:Heart Failure - Basic HemodynamicsOriginal Scenario Developer(s):Lindsey Shank RN MS CNS CCRN12/03/07Date - original scenario11/20/08 Kate McDonald, RNValidation:Revision Dates:Transfer to new template 8/17/10; 1/30/13 bldPilot testing:Approved 8/2010 cokQSEN revision:1/30/13 Barbara Durham MSN, RN, CNEEstimated Scenario Time: 20 minDebriefing time:30-45 minTarget group: Beginning level critical care nurses meant to practice and/or validate orientees’ ability tointerpret hemodynamic measurement and identify appropriate treatments.Senior nursing students learning hemodynamic monitoring.Core case: Basic Hemodynamics in patient with acute bi-ventricular heart failureQSEN Competencies: Teamwork and Collaboration Evidence-Based Practice Patient Centered Care SafetyBrief Summary of Case:Elroy Tyler is a 72-year-old male admitted yesterday evening with acute heart failure exacerbation. Hisprevious medical history (PMH) includes: COPD, HTN and cardiomyopathy. PSH: none. Social history: Drinks2 beers per night. Smokes 1 pack of cigarettes per day. Lives with wife. Has 5 children, all married. Shortlyafter admission, the Intensivist decided to place a pulmonary artery line to guide therapeutic interventions.You enter Mr. Tyler’s room and observe him working very hard to breathe. He appears restless and anxiousand is trying to pull out his IV.Key Contextual Details:It is 0745. Report has just been completed. An experienced telemetry orientee working with you. Otherresources include a charge nurse and resource nurse present on your side of the CCU. The Intensivist &residents are rounding on the other side of the unit and are available by phone.EVIDENCE BASE / REFERENCES (APA Format)Fundamental of Hemodynamic Monitoring: Self study packet by Orlando Health, Education andDevelopment (2011).Cotter, G., Metra, M., Millo-Cotter, O., Dittrich, H.C., and Gheorghiade, M. (2008). Fluid overload in acuteheart failure: Redistribution and other factors beyond accumulation. European Society of u, I. (2013). Heart Failure. Retrieved from Medscape Reference rview (Or agency based protocols)Cronenwett et al. (2007). Quality and safety educations for nurses. Nursing Outlook, 55, 3, 122-131.CSA REV template (12/15/08; 5/09; 12/09; 4/11, 1/15)ALL DATA IN THIS SCENARIO IS FICTITIOUS

2SECTION II: CURRICULUM INTEGRATIONA. SCENARIO LEARNING OBJECTIVESLearning Outcomes1. Apply clinical decision making skills in interpreting and analyzing data in evolving situations.2. Apply principles of pharmacology and medication safety to patient situation.3. Communicate with team members, adapting own style of communicating to needs of team/ situation.4. Prioritize interventions based on accurate interpretation of assessment data5. Base individualized care plan on patient values, clinical expertise and evidence.Specific Learning Objectives1. Apply principles of hand hygiene, infection control and personal protection.2. Correctly identify patient and introduces team3. Demonstrate accurate assessment of the client with focus on the cardiovascular and respiratory system.4. Demonstrate situational awareness and immediately applies O2 during patient assessment.5. Communicate effectively with patient and family to decrease anxiety and inform about plan of care.6. Communicate status to physician using standardized SBAR tool.7. Understand principles of hemodynamic monitoring.Critical Learner Actions1. Perform hand hygiene, introduce self and role, identify patient using two patient identifiers2. Recognize clinical manifestations; prioritize nursing interventions for patients with cardiac output.3. Communicate with family to decreased anxiety and allay concerns.4. Address oxygen supply and demand issues.5. Determine abnormal hemodynamic parameters that need manipulation to improve patient’s condition.6. Make accurate recommendations for pharmacological therapy for a patient in acute decompensated HF.7. Administer drugs using standard safety protocols & document accurately.B. PRE-SCENARIO LEARNER ACTIVITIESPrerequisite CompetenciesKnowledge Completion of ECCO PACEP Modules Interpretation of pulmonary arterymeasurementsInterprofessional communication withphysician regarding change of status.Hemodynamic Monitoring SOP Pulmonary Artery SOP Skills/ AttitudesPulmonary artery set-up and maintenance Pulmonary artery measurements; hemodynamiccalculations.Medication/titratable administration; IV TherapySBAR communication in evolving situationsProtocol for taking verbal (telephone) orders Patient/family communication in evolving situations CSA REV template (12/15/08; 5/09; 12/09; 4/11, 1/15)ALL DATA IN THIS SCENARIO IS FICTITIOUS

3SECTION III: SCENARIO SCRIPTA.Case summaryElroy Tyler is a 72-year-old male admitted yesterday evening with acute heart failure exacerbation. His previousmedical history (PMH) includes: COPD, HTN and cardiomyopathy. PSH: none. Social history: Drinks 2 beers pernight. Smokes 1 pack of cigarettes per day. Lives with wife. Has 5 children, all married. Shortly after admission,the Intensivist decided to place a pulmonary artery line to guide therapeutic interventions.B. Key contextual detailsIt is 0745 in your unit and you have just completed report. You enter Mr. Tyler’s room and observe him workingvery hard to breathe. He appears restless and anxious and is trying to pull out his IV. You have an orienteeworking with you who is an experienced Telemetry nurse. There is also a charge and resource nurse present onyour side of the CCU. The Intensivist and residents are rounding on patients on the other side of the unit andare available by phone.C. Scenario CastPatient/ Client RolePrimary NurseOrienteeResource NurseCharge NurseIntensivistWifeHigh fidelity simulatorMid-level simulatorTask trainerHybrid (Blended simulator)Standardized patientBrief Descriptor(Optional)Available by phone. Ask nurse to get new set ofHemodynamic measurements. Ask nurse to interpret PAnumbers. Speak into phone while ordering 1L fluid bolusfor another patient to see if nurse will questionrationale.Use to practice patient/family centered care. In roomsitting next to patient. Asks nurse, “What is going onhere. Do you people know what you’re doing? Myhusband is getting worse.CSA REV template (12/15/08; 5/09; 12/09; 4/11, 1/15)ALL DATA IN THIS SCENARIO IS FICTITIOUSConfederate/Actor (C)or Learner tor/Confederate

4D.Last name:TylerGender: MaleAge: 72Spiritual Practice: ChristianPatient/Client ProfileFirst name:Ht: 65 inWt: 79.1 kg/29 BMIEthnicity: CaucasianElroyCode Status: FullPrimary Language spoken: English1. History of present illnessMr. Tyler was brought in by ambulance yesterday after a 1 day history of shortness of breath, dry cough, pedaledema, JVD. And extreme fatigue. Mr. Tyler stopped taking his medications after experiencing impotence lastweek that he attributed to the medications used to treat his heart failurePrimary Medical DiagnosisAcute Bi-ventricular Heart Failure2. Review of SystemsCNSAwake, alert & oriented x 4. MAE w/o difficulty, pupils, equal, round, reactive to light.No deficits. Denies all pain or discomfort.CardiovascularS1 S2, S3, no murmurs, bruits, or thrills, positive JVD, 3 pedal edema in bilateral lowerextremities, peripheral pulses (radial & pedal), capillary refill prolonged (5 seconds),skin, pale, cool, moist and intact. PCXR shows LV hypertrophy, bilaterally pleuraleffusions and vascular congestion. ECG shows sinus tachycardia (rate 123) andventricular hypertrophy. Patient has rare multifocal PVCs, no Q wave, and no BBB.PulmonaryRespirations rapid, labored with use of accessory muscles. C/O SOB. Lungs: coarsecrackles bilaterally.Renal/HepaticFoley catheter with small amount of cloudy, yellow urine.GastrointestinalWNLEndocrineLast BS taken at 1739 124.Heme/CoagWNLMusculoskeletalWNLIntegumentSkin, pale, cool, moist and intact.Developmental HxHx of noncompliance with outpatient treatment regimen. Currently cooperative withhospital care.Psychiatric HxNone reported.Social HxMarried w ith 5 grown children, Retired salesman. Drinks 2 beers per night. Smokes 1pack of cigarettes per day.Alternative/ Complementary Me dicine HxNone3. CurrentmedicationsMedication allergies:Food/other e (Natrecor) to be startedLasixDobutamineDose0.01mcg/kg/min.80 mg5 mcg/kg/minSkin rashRouteFrequencyIV gttContinuous gttIVPIV gttBIDContinuous gttCSA REV template (12/15/08; 5/09; 12/09; 4/11, 1/15)ALL DATA IN THIS SCENARIO IS FICTITIOUS

54. Laboratory, Diagn stic Study ResultsNa: 145K: 4.5Ca:Mg: 2.2Hgb: 15.2Hct: 43.3ALT 56PT 19.3PTT 22Ammonia:Amylase:ABG-pH: 7.3paO2: 65VDRL:GBS:CXR: LV hypertrophy, bilateral pleuraleffusions and vascular congestionCT:Cl: 105Phos:Plt: 340kCholesterol 300INR 1.1Lipase:paCO2: 52Herpes:HCO3: 28Glucose: 106WBC: 7.9LDL 200Troponin:Albumin:HCO3/BE: 34/-6HIV:BUN: 25Cr: 1.5HgA1C:BNP: 345 ( 100 HF)HDL 25Lactate:SaO2: 90%Fraction 29%MRI:E. Baseline Simulator/Standardized Patient State(This may vary from the baseline data provided to learners)1. Initial physical appearanceGender: MaleAttire:Alterations in appearance (moulage):Ice bags to face, chest, arms and lower legs for 15 minutes prior to start of simulation. Bluish colorationaround mouth and ear lobes. Water/glycerin spray just prior to scenario starting. Bed clothing & bed sidetable-disarray.xxID band present,accurate informationAllergy band present,accurate informationID band present,inaccurate informationAllergy band present,inaccurate informationID band absent or notapplicableAllergy band absent or notapplicable2. Initial Vital Signs Monitor display in simulation action room:No monitorMonitor on, but no x Monitor on,displaydata displayedstandard displayBP: 88/51CVP: 18AIRWAY:HR: 123RR: 28T: 97.6FSpO²: 90PAS: 55PAD: 27PCWP: 26CO: 2.48 L/minETC0²:FHR:Lungs: Left: Course CracklesRight: Course CracklesSounds/mechanicsHeart: Sounds:S1, S2, S3ST w/few multifocal PVCsECG rhythm:Additional Hemodynamic measures:Other:Bowel sounds: hypoactiveCI 1.32, PVR 322, SVR 1857,RVSWI 6.2, LVSWI 30.7Other:CSA REV template (12/15/08; 5/09; 12/09; 4/11, 1/15)ALL DATA IN THIS SCENARIO IS FICTITIOUS

63. Initial Intravenous line set upSalineSite:lock #1Fluid type:Site: RFAX IV #1Natrecor 1.5 mg inX Main250 ml NSPiggybackFluid type:x IV #2Site: RHDobutamine 1,000Mainmg in 250 ml NSPiggyback4. Initial Non-invasive monitors set upx NIBPx ECG First lead: IIx5.x6.xIV patent (Y/N)Initial rate:X IV patent (Y/N)YesInitial rate:x0.01 mcg/kg/min8ml.hr5 mcg/kg/min6ml/hrxIV patent (Y/N)YesECG Second lead: V1Temp monitor/type:Other:Blood tempInitial Hemodynamic monitors set upA-line Site:Catheter/tubing Patency (Y/N) YES CVP Site: PACPAC Site: RSCOther monitors/devicesFoley catheterAmount: 75mlAppearance of urine: amber, concentrated urineEpidural catheterInfusion pump:Pump settings:Pulse oximeterx3 channelFetal Heart rate monitor/tocometerNatrecor: 8 ml/hr; Dobutamine: 6 ml/hrInternalExternalEnvironment, Equipment, Essential propsRecommend standardized set ups for each commonly simulated environment1. Scenario setting: (example: patient room, home, ED, lobby)ICU patient room2. Equipment, supplies, monitors(In simulation action room or available in adjacent core storage rooms)xxBedpan/ UrinalIV Infusion pumpNasogastric tubexDefibrillatorPCA infusion pumpxIV fluidType:NSPrimary,secondary;Pressure tubingFoley catheter kitFeeding pumpETT suctioncathetersCode CartEpidural infusionpumpIV fluid additives:xxStraight cath. kitPressure bagOral suction catheters12-lead ECGCentral line InsertionKitStrips for CVP, PAP,PAOP that are close tothe parameters givenon the monitor- E2CSA REV template (12/15/08; 5/09; 12/09; 4/11, 1/15)ALL DATA IN THIS SCENARIO IS FICTITIOUSxIncentive spirometerWall suctionChest tube insertionkitChest tube equipDressing equipmentBlood productABO Type:# of units:

73. Respiratory therapy equipment/devicesX Nasal cannulaFace tentxBVM/Ambu bagNebulizer tx kit4. Documentation and Order FormsHealth Carexx Med AdminProvider ordersRecordxProgress Notesx Graphic recordxxxMedicationTransfer ordersreconciliationNurses’ NotesDx test reportsActual medical record binder, constructedper institutional guidelinesxSimple Face Maskx Non re-breather maskFlowmeters (extra supply)xH&P1,000 mg in 250 ml NSNatrecor gtt1.5 mg in 250 ml NSLasix 100 mg vialHydralazinePt weight 79.1 kg5 mcg/kg/min6ml/hr0.01mcg/kg/min8ml/hr80 mgIV20 mg –40 mgIVLab ResultsAnesthesia/PACUED RecordrecordStanding (protocol)ICU flow sheetordersCode RecordPrenatal recordOther Describe: CVP, PAOP, PAP &Hemodynamic numbers with same values fromscenario.5. Medications (to be available in sim action room)# MedicationDosageRoute#Dobutamine gttxMedicationIVIVCSA REV template (12/15/08; 5/09; 12/09; 4/11, 1/15)ALL DATA IN THIS SCENARIO IS FICTITIOUSDosageRoute

8CASE FLOW / TRIGGERS/ SCENARIO DEVELOPMENT STATESInitiation of Scenario: Report from off-going night nurse @0745: Mr. Tyler was brought in by ambulance yesterday after a 1 day history ofshortness of breath, dry cough, pedal edema, JVD and extreme fatigue. Mr. Tyler stopped taking his medications after experiencing impotencelast week that he attributed to the medications used to treat his heart failure. Shortly after admission, the Intensivist decided to place apulmonary artery line to guide therapeutic interventions. Social history: Mr. Tyler drinks 2 beers per night, smokes 1 pack of cigarettes per dayand lives with wife. He has 5 grown children.Past Medical History: includes COPD, HTN and LV hypertrophy. Past Surgical History: none.VS upon admission were BP 180/98, HR 115, RR 24, T 99.4 ECG shows ST with LV hypertrophy.STATE / PATIENT STATUS1. BaselinePt. demonstrates extremeeffort to breathe w/ HOB 30 Appears restless and anxious verbalizes wanting IV out.(trying to pull out IV) Wife atbedside will verbalize this tonurses.Dobutamine infusing per MDorderWife at bedside sitting next topatient. Very anxious - Asksnurse, “What is going on here.Do you people know whatyou’re doing? My husband isgetting worse. He keeps tryingto pull this IV out”.DESIRED LEARNER ACTIONS & TRIGGERS TO MOVE TO NEXT STATEOperatorVital Signs:BP 88/51;HR 123,RR 28; SpO2 90%,T 97.6 F,Lung sounds: Course cracklesHemodynamic numbers:Initial:PAP 58/29; CVP 18, PAOP 27CO 2.52; CI 1.32,PVR 368, SVR 1923,RVSWI 6.1, LVSWI 20.Triggers:Completes Learner Actionswithin 5 minutes.Learner Actions Washes hands, identifies selfand team membersFocused cardiovascular &respiratory assessments.Increase O2 delivery using facemask or 100% non-re-breathermask (NRB).Changes position to improveoxygenationConfirms transducers are levelwith phlebostatic axis, performssquare wave test, re-zerostransducer after repositioningpatient.Analyzes and interpretshemodynamic valuesCommunicate with pt./ familymembers to their anxietywhile monitoringCSA REV template (12/15/08; 5/09; 12/09; 4/11, 1/15)ALL DATA IN THIS SCENARIO IS FICTITIOUSDebriefing Points: Strategies for complying withNPSG’s in acute situationsSigns and symptoms ofdecreasing cardiac output andhemodynamic compromise (pt isexperiencing acutedecompensated heart failure)Discuss NYHA classesSignificance of clinical findingsStrategies for communicatingwith family to minimize fears andanxiety during emergent situation

9STATE / PATIENT STATUSDESIRED ACTIONS & TRIGGERS TO MOVE TO NEXT STATEOperator:Learner Actions:Patient remains in the samestate.Vital Signs:BP 86/49;T 97.6 F.HR 125,RR 28SpO2 90% if oxygen has notyet been increasedSpO2 92% if O2 to face maskSpO2 94% if NRB. 2.Patient is less confused andagitated as SpO2 increases.Hemodynamic readings:After zero and reposition:PAP 60/31; CVP 20, PAOP 30CO 2.22; CI 1.12,PVR 378, SVR 2067,RVSWI 5.9, LVSWI 20.4Triggers:MD arrives-gives orders toperform all actions in listed inLearner Actions if Learnershad not already done. Obtain new set of hemodynamicnumbers.Identifies hemodynamicparameters that need to bemanipulated in order to improvepatient condition (CVP).Notify MD of patient statuscommunicate using ISBAR.(reports CVP and recommendsLasix to preload orHydralazine afterload orNesiritide to both)Follows read back and verifywhen obtaining MD ordersContinue assessmentContinue communicating withfamily to keep apprised of thesituation.CSA REV template (12/15/08; 5/09; 12/09; 4/11, 1/15)ALL DATA IN THIS SCENARIO IS FICTITIOUSDebriefing Points: Immediate nursing interventionfor patients with hemodynamiccompromiseo need to preload to improveCVP, PAP and wedge pressureo by afterload, contractilityand ventricular stroke workindex will improveStrategies for communicatingwith physician to minimize risksof error during reporting changeof statusRationale for recommendedpharmacological therapy (seeabove)

10STATE / PATIENT STATUSDESIRED ACTIONS & TRIGGERS TO MOVE TO NEXT STATEOperator:Learner Actions:Patient remains in the samestate.After Lasix given:Vital Signs:BP 86/49;T 97.6 F.HR 115,RR 24SpO2 45% if O2 to face maskSpO2 96% if NRB. 3.Continues with increased WOB,until approx. 5 min after Lasixgiven, patient will be able tobreath easier.Hemodynamic readings:After Lasix:PAP 57/27, CVP 18, PAOP 28Triggers:Learner actions completewithin 10 minutesMD orders Administer Lasix IVP first thenestablish Nesiritide dripObtain new set of hemodynamicnumbers.Reassesses patient followingmedication administrationProvide patient information andeducation in a manner clearlyunderstood by thepatient/familyDebriefing Points: Decision-making and prioritysetting in regards to interventionsto be carried out firstEvaluate effectiveness ofinterventions by reassessingcritical parametersImportance of continuedreassessment of unstable patientScenario End Point:Treatment team perform all of the actions that are listed or when MD orders them (MD will order actions if treatment team has failed to do soafter 15 minutes. After debrief, consider running the same scenario so the participants have the opportunity to execute the behaviors they havelearned.Suggestions to decrease complexity: Change hemodynamic values to normal and have orientee practice zeroing and leveling the transducer; orkeep same values and provide MD orders to be carried out.Suggestions to increase complexity: Progress patient to full decompensated HF requiring intubation and mechanical ventilation.Normal Hemodynamic Values: CVP 0-8 mm Hg, CO 4-8 L/min, CI 2.5-4.5 L/min/m2, PAP 15-30/8-15 mmHg, PAOP (wedge) 8-12 mmHg, PVR 120200 dynes, SVR 800-1200 dynes, SV 50-100 ml/beat, LVSWI 43-62 g/m/ m2, RVSWI 7-12 g/m/ m2CSA REV template (12/15/08; 5/09; 12/09; 4/11, 1/15)ALL DATA IN THIS SCENARIO IS FICTITIOUS

11APPENDIX A: HEALTH CARE PROVIDER ORDERSPatient Name:Diagnosis:DOB:Age:MR#: No Known Allergies Allergies & SensitivitiesDateTimeHEALTH CARE PROVIDER ORDERS AND SIGNATURESignatureCSA REV template (12/15/08; 5/09; 12/09; 4/11)

12APPENDIX B: Digital images of manikin and/or scenario milieuInsert digital photo hereInsertInsertdigitaldigitalphotophotohereof initialscenario set up hereInsert digital photo hereInsert digital photo hereCSA REV template (12/15/08; 5/09; 12/09; 4/11)

13APPENDIX C: DEBRIEFING GUIDEGeneral Debriefing PlanWith VideoIndividualGroupDebriefing GuideDebriefing MaterialsObjectivesDebriefing PointsWithout VideoQSENQSEN Competencies to consider for debriefing scenariosPatient Centered CareTeamwork/CollaborationEvidence-based PracticeSafetyQuality ImprovementInformaticsSample Questions for Debriefing1. How did the experience of caring for this patient feel for you and the team?2. Did you have the knowledge and skills to meet the learning objectives of the scenario?3. What GAPS did you identify in your own knowledge base and/or preparation for thesimulation experience?4. What RELEVANT information was missing from the scenario that impacted yourperformance? How did you attempt to fill in the GAP?5. How would you handle the scenario differently if you could?6. In what ways did you check feel the need to check ACCURACY of the data you were given?7. In what ways did you perform well?8. What communication strategies did you use to validate ACCURACY of your information ordecisions with your team members?9. What three factors were most SIGNIFICANT that you will transfer to the clinical setting?10. At what points in the scenario were your nursing actions specifically directed towardPREVENTION of a negative outcome?11. Discuss actual experiences with diverse patient populations.12. Discuss roles and responsibilities during a crisis.13. Discuss how current nursing practice continues to evolve in light of new evidence.14. Consider potential safety risks and how to avoid them.15. Discuss the nurses’ role in design, implementation, and evaluation of informationtechnologies to support patient care.Notes for future sessions:CSA REV template (12/15/08; 5/09; 12/09; 4/11)

Elroy Tyler is a 72-year-old male admitted yesterday evening with acute heart failure exacerbation. His previous medical history (PMH) includes: COPD, HTN and cardiomyopathy. PSH: none. Social history: Drinks 2 beers per night. Smokes 1 pack of cigarettes per day. Lives with wi

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