Morning Triage in Phase II Cardiac Rehabilitation
It is 7:00 a.m. in a supervised phase II cardiac rehabilitation gym. You are the only exercise physiologist on the floor, working with one nurse. Four patients are waiting:
- A: 64-year-old woman, two weeks post CABG, sternal incision intact, BP 132/78, HR 88, no symptoms.
- B: 59-year-old man, three weeks post ICD implantation for secondary prevention, EF 25%, wants to walk fast on the treadmill and do overhead presses.
- C: 71-year-old man with type 2 diabetes, pre-exercise glucose 72 mg/dL, asymptomatic.
- D: 55-year-old man, BP 182/106 after five minutes of quiet sitting, no symptoms, says he took his medications this morning.
1. Triage the four patients: who exercises as planned, who needs modification, and who is deferred? Give your reasoning.
Read the worked answer
- A: Exercise as planned, with sternal precautions: no upper-body resistance, no lifting, no pushing or pulling through the arms for roughly 6–8 weeks per surgical protocol. Walking and lower-body work are appropriate.
- B: Exercise, but modify. Lower-body walking at RPE 11–13 is fine; avoid overhead presses and heavy upper-body work because of the implant site, typically for 4–6 weeks after implantation. Avoid maximal exertion and high-intensity intervals early after implantation. Confirm device parameters with electrophysiology.
- C: Defer exercise until glucose is corrected. A glucose of 72 mg/dL is below the threshold for safe exercise; give 15 g of fast-acting carbohydrate, recheck in 15 minutes, and exercise only after it is above about 100 mg/dL.
- D: Recheck BP after another 5 minutes of rest. If systolic remains above 180 mmHg, defer exercise and notify the referring clinician; a resting systolic >180 mmHg is a reason not to proceed. Do not simply exercise him at a lower intensity.
2. Patient B asks to do overhead presses and a fast treadmill walk. How do you respond, and what device-related restrictions apply?
Read the worked answer
Respond directly and without ambiguity: "The fast walk is fine at a comfortable pace; the overhead presses are not yet, because of where your device sits under the pectoral muscle." Offer an alternative: seated lower-body work, band work kept below shoulder height on the non-implant side, and walking at RPE 11–13.
Restrictions after ICD implantation generally include avoiding lifting more than about 5–10 lb and avoiding raising the arm above shoulder level on the implant side for roughly 4–6 weeks, to prevent lead dislodgment. Heavy resistance and Valsalva increase intrathoracic pressure and are avoided early. Because his EF is 25% and the device was placed for secondary prevention, keep intensity below the level at which he becomes symptomatic and avoid maximal exertion.
If he insists or describes symptoms, involve the electrophysiology team rather than negotiating the restriction yourself.
3. You are the only exercise physiologist on the floor with a nurse. What staffing and emergency considerations shape the session plan?
Read the worked answer
Plan the session so that no patient is out of direct line of sight and no staff member is committed to a task they cannot leave. That means staggering starts, keeping the highest-risk patient (B) near the nurse, and not running a treadmill orientation while monitoring someone else.
Before the first patient starts: confirm the emergency plan, AED location and readiness, oxygen, and the nearest phone; confirm that both staff have current BLS and that a code response can be activated without leaving the floor. Run periodic drills and document them.
If the acuity exceeds what two staff can safely supervise, the correct professional decision is to reduce the schedule or defer a patient, not to stretch coverage. Document the triage decisions, the glucose and BP values, and the reasons for any deferral, and notify the referring clinicians.