{"id":552,"date":"2023-12-04T10:26:12","date_gmt":"2023-12-04T15:26:12","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/chapter\/emergency-room-4\/"},"modified":"2023-12-04T10:26:12","modified_gmt":"2023-12-04T15:26:12","slug":"emergency-room-4","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/chapter\/emergency-room-4\/","title":{"raw":"Emergency Room","rendered":"Emergency Room"},"content":{"raw":"\n

Day: 0<\/h2>\n

Time: 22h30<\/h3>\n

Place: Emergency Room<\/h3>\nNurse Jackie, on the triage desk tonight, let\u2019s out a long sigh, and says to herself, \u201cBeen a quiet evening so far.\u201d Jackie has her back to the waiting room and is updating the census when she hears, \u201cExcuse me, can you help my husband? I think he\u2019s having a heart attack!\u201d\n\nJackie immediately turns around and looks at the two people standing at the triage desk. She sees two middle-aged East Asian individuals: one, a woman who looks about to burst into tears and a man, quite overweight, hair a bit messed up, and rubbing his left shoulder.\n\n\u201cCan you say that again? Your husband is having chest pain?\u201d\n\nPriya, looking a bit exasperated and tired at the same time, says, \u201cYes, he thinks it\u2019s nothing but indigestion, but since dinner he has been rubbing his shoulder and complaining of not feeling well. He took some Tums but that didn\u2019t help. He blames my cooking, but we\u2019ve been married for over 25 years. If my cooking was a problem, he would be slimmer.\u201d\n\nJackie looks at both of them again and nods. She quickly comes out from the triage desk and grabs a nearby wheelchair. \u201cMr\u2026?\u201d\n\n\u201cMy name is Harj Singh and I don\u2019t need a wheelchair.\u201d\n\n\u201cPlease have a seat, Mr. Singh, and let\u2019s humour your wife and me. It looks to me like you\u2019re having some difficulty breathing. You are rubbing your arm and upper chest, and you look a bit paler than I would expect.\u201d\n\nHarj plops down into the wheelchair with a huff, looking quite unhappy with the whole situation. Priya reaches down and squeezes his hand.\n\nJackie squats down to talk directly to Harj and Priya. \u201cWe take chest pain very seriously, so a lot of things are going to happen real quick. I am going to take you back in behind my desk to a special room. We\u2019re going to take your blood pressure and other vitals and have a doctor look quickly at you. We\u2019ll probably give you some medications to see if we can relieve the pain in your arm and chest. Your wife can stay with you, as we\u2019ll need to understand more of how this started. But then I\u2019ll ask her to step away to the admitting desk to give them some information. Are you ready?\u201d\n\nHarj and Priya now both look quite scared, but nod affirmative.\n\nJackie moves behind the wheelchair, rapidly pushes it to the acute side of the Emergency Room, and enters Trauma Room 1. As she enters the trauma room, she nods to two other emergency nurses who come over. \u201cHey, Jackie, anything we can do to help?\u201d\n\n\u201cYes, can you let Dr. Smythe know that we have a patient with chest pain in Trauma 1. Can you also get me ASA <\/a>and some nitrospray<\/a>. I\u2019ll also need someone to start an IV <\/a>on Mr. Singh.\u201d\n\nOne of the nurses moves quickly over to the unit coordinator to page Dr. Smythe and the other nurse, Carrie, assists Jackie to get Mr. Singh onto the trauma room stretcher.\n\n\u201cOk, Mr. Singh. Carrie here is going to help you remove your shirt. She is also going to start an IV in your left arm, in case we need to give you some fluids. I am going to take your vital signs.<\/a>\u201d\n\nJackie wraps the blood pressure cuff around Harj\u2019s right arm, places an SpO2<\/sub> probe on his left forefinger, and puts a temperature probe under his tongue. Carrie grabs the monitor leads and places five leads on Harj\u2019s chest. She turns the monitor on.\n\nLooking at the vital sign machine, Jackie records the vital signs onto the Emergency Record.\n\n\n\n\n
Day: 0<\/strong><\/td>\nPulse Rate<\/strong><\/td>\nBlood Pressure<\/strong><\/td>\nRespiratory Rate<\/strong><\/td>\nTemperature<\/strong><\/td>\nO2 Saturation<\/strong><\/td>\n<\/tr>\n
Time: 22:00<\/strong><\/td>\n96<\/td>\n180\/90<\/td>\n28<\/td>\n36.5\u00b0C<\/td>\n95%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\nLooking up at the monitor, she notes that Harj is in normal sinus tachy with some ST depression noted on leads II and III.<\/a>\n\n\u201cNow that is done, are you having pain in your chest?\u201d\n\nHarj nods 'yes'.\n\n\u201cHave you had this type of pain before?\u201d\n\nPriya looks anxiously at her husband. Harj, looking down at his belly, says, \u201cYes, but only for a short time. When I sat down it went away.\u201d\n\nPriya looks horrified. \u201cYou never told me! What am I to do with you?\u201d\n\n\u201cIt\u2019s ok, Mrs. Singh. This is quite usual. Denial is quite common. Mr. Singh, if you were to rate your pain <\/a>on a scale of 1 to 10, with 1 being barely able to feel any discomfort and 10 being the worse pain you have ever felt, what would you say your pain is right now?\u201d\n\n\u201cIt\u2019s about 5 out of 10.\u201d\n\n\u201cRight, I am going to give you an aspirin and spray some medication under your tongue. It tastes terrible and may give you a bit of a headache as well. Do you have any drug allergies? What medications are you currently taking?\u201d\n\nPriya looks at Jackie. \u201cHe is on HCTZ<\/a>. Sorry, I can\u2019t say the whole name. One tablet in the morning for high blood pressure.\u201d\n\nJackie looks at them both. \u201cDo you take any Viagra<\/a> or Cialis<\/a>?\u201d\n\nBoth Harj and Priya look at each other and shake their heads 'no'.\n\n\u201cThe reason I asked is that those drugs can cause a very low blood pressure with the medication I am going to spray under your tongue.\u201d\n\nJackie hands Harj a small med cup with a tiny blue 81 mg ASA in the bottom of the cup.\n\n\u201cI want you to chew this aspirin. It will taste awful, so here is a cup of water to rinse and swallow after.\u201d\n\nHarj takes the ASA and chews the medication, making a sour looking face, and drinks all the water from the cup in one swallow.\n\n\u201cOk, I am going to now spray some medication under your tongue. Please open your mouth and put the tip of your tongue on the roof of your mouth.\u201d\n\nHarj does as he is told and Jackie sprays nitro<\/a> twice under his tongue. \u201cLet\u2019s give that a couple of minutes to see if that helps your chest pain.\u201d\n\n\u201cJackie, the IV is in Mr. Singh\u2019s left ACF<\/a>. I have NS running at 25 cc\/hour<\/a> on the pump right now. Are you ok?\u201d\n\n\u201cThanks, Carrie. I should be fine. Mr. Singh doesn\u2019t look critical right now. I will call if we need help. Can you cover the triage desk for a little bit while we get Mr. Singh settled?\u201d\n\n\u201cYes, no problem. I\u2019ve done that before. I\u2019ll call you if I need help. Then maybe we can switch?\u201d\n\n\u201cSure thing. Thanks.\u201d Jackie reaches over and pushes the NIBP button<\/a> again to see how Harj\u2019s blood pressure is after the nitro sprays. She then enters the number in the emergency record.\n\n\u201cGood evening, I\u2019m Dr. Smythe. Can you give me an update here, Jackie?\u201d\n\nJackie looks up at the doctor who has entered the trauma room. \u201cHello, Dr. Smythe. This is Mr. and Mrs. Singh. Mr. Singh came in with a complaint of chest pain radiating to left arm and jaw. We have given him two sprays of nitro, 81 mg of ASA, and oxygen saturations are above 93%<\/a>, so I have not given him oxygen. I was just about to inquire as to his chest pain and call you about additional orders.\u201d\n\n\u201cThank you, Jackie. Mr. Singh, how do you feel right now?\u201d\n\nHarj looks up and sees a well-dressed, bow-tied traditional looking doctor in a short, white coat. \u201cI am doing ok right now. I think everyone is making a bigger deal about this than is necessary. I need to get to work in the morning or I don\u2019t get paid.\u201d\n\n\u201cLet\u2019s deal with one issue at a time here. Can you tell me about your chest pain?\u201d\n\nHarj rolls his eyes, then begins to explain that he had this type of chest pain a couple of weeks ago, but it went away when he rested in the cab of his truck. Today, after dinner, it came back. He took some antacids, but it did not go away.\n\n\u201cIt felt like dull heavy pressure, with some numbness to my left arm.\u201d\n\nPriya adds, \u201cHe complained of feeling tired, and I had to help him walk to the car, as he was so short of breath and tired. He also looks pale.\u201d\n\n\u201cDo you smoke, Mr. Singh?\u201d\n\nPryia says, \u201cWay too much. At least a pack a day.\u201d\n\n\u201cOh, come on! I don\u2019t smoke that much.\u201d\n\n\u201cYes, you do. I see the empty packs in the recycling box.\u201d\n\n\u201cDo you drink alcohol?\u201d\n\n\u201cYes, I have a drink after work.\u201d\n\n\u201cMore like two or three drinks after work. Harj, they are trying to help you, not criticize you. Tell them the truth!\u201d\n\n\u201cOk, I have two to three drinks per evening of Crown Royal.\u201d\n\nDr. Smythe and Jackie write the information down. \u201cThank you, Mr. Singh. What about your work? Is it stressful?\u201d\n\n\u201cNot really. I run a small trucking delivery company. Things have been tight, but not especially so.\u201d\n\nPriya rolls her eyes. \u201cWe are barely making ends meet. Everyday Harj is out fixing the truck. He is up at 5am and doesn\u2019t usually come home till after 6pm.\u201d\n\n\u201cThat sounds a bit stressful. Do you have any activities other than work, Mr. Singh?\u201d\n\n\u201cIf you are asking, do I exercise, no.\u201d\n\n\u201cRight, how would you describe your chest pain now?\"\n\n\u201cA bit less than when I came in. Oh, right, you want a number. Three out of 10. The sprays helped, but it has really made my head ache.\u201d\n\nDr. Symth looks at Jackie. \u201cHow long since the last spray of nitro?\u201d\n\nJackie consults the emergency record. \u201cA little over five minutes.\u201d\n\n\u201cOk, give him two more sprays of nitro, and if the chest pain doesn\u2019t go away, try morphine, 1-2 mg IV, till the pain is gone. I\u2019ll write that down for you. Plus, let\u2019s get some lab work, including CBC,<\/a> lytes,<\/a> BUN,<\/a> creatinine<\/a>, Trops,<\/a> 12 lead,<\/a> and a portable chest X-ray<\/a>.\u201d\n\nJackie nods her head and makes note of what Dr. Smythe has stated.\n\nDr. Smythe moves over to the same side of bed that Priya is on. \u201cI\u2019m not positive that your husband is having a heart attack. We need to do some tests, then we will know more. I\u2019m going to keep him here until we have those results.\u201d\n\n\u201cAww, Doc,\u201d Harj says, \u201cYou are going to cost me money to do this.\u201d\n\nPryia grabs his hand. \u201cBetter a day\u2019s pay than a dead husband.\u201d\n\nHarj rolls his eyes and leans back into his pillow with a sigh of exasperation.\n\n\u201cMrs. Singh, why don\u2019t you follow me out to the admitting desk so we can get all of your contact information, and then you can call any other family. Jackie will take good care of your husband.\u201d\n\nDr. Smythe leads Priya out to the admitting desk and introduces her to the clerk there. \u201cYou can give your contact information to the clerk. When you\u2019re done, just go to the desk where you came in and ask to see your husband. They will guide you to him.\u201d\n\nPriya thanks Dr. Smythe.\n\nDr. Smythe returns to the unit clerk\u2019s desk and asks her to have the lab and X-ray come to see Mr. Singh in Trauma 1.\n\nShe looks up at him. \u201cJackie already called me to let me know that she put the order into the computer as stat. They should be coming shortly. Do you want to add anything?\u201d\n\n\u201cNo, that\u2019s a good start. Let\u2019s see what the results are and go from there. He may not need to be admitted if it\u2019s just angina.\u201d\n

Time: 21h55<\/h3>\nJackie confirms with Mr. Singh that his chest pain is still three out of 10 and sprays two more doses of nitro under his tongue.\n

Place: Medical Laboratory\n<\/strong><\/h3>\nAlexa, just about to leave the Emergency Department and head to the lab to drop off some specimens and restock her cart, looks down at her buzzing pager, and thinks, Stat lab work in Trauma 1. That takes precedence over going to the lab. Looks like my break will be a bit later than usual<\/em>.\n\nTurning around her white cart, Alexa walks quickly to Trauma 1.\n\nEntering Trauma 1, Alexa sees an overweight middle-aged East Asian male and Jackie, the nurse that is usually at the triage desk.\n\n\u201cHi, Jackie. I\u2019m here from the lab. You requested some stat blood work?\u201d\n\nJackie turns around and smiles. \u201cHi, Alexa. Thank you for coming so quick. Yes, this is Mr. Harj Singh. We are investigating him for unstable angina, possible MI<\/a>.\u201d\n\n\u201cOk, do you have the labels?\u201d\n\n\u201cYes, they\u2019re over there on the printer.\u201d\n\nAlexa walks over to the label printer and pulls off three labels for Mr. Harj Singh.\n\nWalking back to Harj\u2019s bedside, Alexa begins the routine of checking identity. \u201cHi, Mr. Singh. My name is Alexa and I\u2019m going to draw some blood for testing. I need to ask you some questions to confirm that you are the right person and that the labels all match up.\u201d\n\n\u201cReally, here is my ID band. Is that not good enough?\u201d\n\n\u201cNo, we really want to make sure we are taking blood from the right patient, as many treatments are based on the results, and you would not want to receive the wrong treatment.\u201d\n\n\u201cAh, yes, you guessed right. I want no mistakes. Ask your questions.\u201d\n\nAlexa goes through the process of confirming name, date of birth, and Mr Singh\u2019s ID number.\n\nOnce satisfied, she efficiently draws the blood<\/a> from Harj\u2019s right antecubital fossa<\/a>.\n\n\u201cAll done, Mr. Singh. Please hold pressure here for another couple of minutes. Jackie, I will take the blood back to the lab and you should have the results for the troponin very quickly.\u201d\n\n\u201cThanks, Alexa.\u201d\n\n\u201cOk, Mr. Singh, can you tell me how your chest pain is right now?\n\nHarj looks up at her. \u201cI think it\u2019s gone.\u201d\n\n\u201cThat\u2019s excellent. We\u2019ll do all of these tests and make sure nothing else is happening, but this is a good sign.\u201d\n

Time: 22h10<\/h3>\nGurpreet checks the list of patient requests and sees that the top request is a portable chest X-ray<\/a> in Trauma 1.  Pulling up the patient data she sees that the patient was admitted with potential MI. \u201cOk,\" she says to herself. \"I can understand them not wanting to transport to the department. Looks like I will do this with the portable machine.\u201d\n\nGurpreet pulls the requisition off the printer and heads straight out the department doors and down the stairs that lead directly to the Emergency Department. At the bottom of the stairs she pulls an imaging plate<\/a> out of the rack and places it in the rear door of the portable X-ray machine. Unplugging the machine, she pushes the portable down the hallway and navigates it through the chaos of people moving around in the Emergency Department into Trauma 1.\n\n\u201cHi, I\u2019m Gurpreet from Medrad here to do a chest X-ray on Mr. Singh.\u201d\n\n\u201cHi, Gurpreet. I\u2019m Jackie and this is Mr. Harj Singh.\u201d\n\n\u201cHello, Mr. Singh. Do you think you can sit straight up and have a very hard board behind you?\u201d\n\n\u201cI think so. Depends on how straight.\u201d Harj points at his belly as he says this.\n\n\u201cWe can work around it. Let\u2019s see.\u201d\n\nBoth Jackie and Gurpreet help Harj to sit up in bed, and they place the hard cassette behind his back.\n\nGurpreet moves to the end of the bed and looks at Mr. Singh. \u201cCan you move a little to your right, that\u2019s it. Hold right there.\u201d\n\nGurpreet moves the machine into position. She pulls the tape measure out of the camera and confirms that it is the appropriate distance away. Looking at Mr. Singh she adjusts the technique settings for exposure. That should work on someone his size<\/em>, she thinks to herself. Pushing a button to bring up the positioning lighting, Gurpreet makes adjustments to capture the chest correctly.\n\n\u201cOk, ready to shoot.\u201d\n\nJackie steps quickly out of the room as Gurpreet grabs the lead shield to cover her neck and chest and pulls the exposure button out as far as the cord goes. \u201cOk, Mr. Singh, take a deep breath and let it out. Ok, ready to shoot. Take a deep breath and hold it ... X-ray! Trauma 1.\u201d\n\nGurpreet presses the exposure button and the portable machine whines up and makes a clicking noise.\n\n\u201cOk, all clear, Mr. Singh. Great job. Let\u2019s get that hard cassette out.\u201d\n\nBoth Jackie and Gurpreet remove the cassette and reposition Harj. \u201cHow is that?\u201d\n\n\u201cI am good, thank you.\u201d\n\n\u201cThanks, Gurpreet. How long till I can see the results?\u201d\n\n\u201cI\u2019ll run it through now and should have it on the system in less than 10 minutes.\u201d\n\n\u201cExcellent.\u201d\n\nGurpreet pushes the machine out and places it back in its special niche. Grabbing the exposed cassette she heads back to the department to process the chest X-ray of Mr. Singh.\n\nJust as Gurpreet is leaving, Dennis from Cardiology pushes his cart in. \u201cI have a req for a 12 lead<\/a> for one Mr. H. Singh with complaint of chest pain. Am I in the right place?\u201d\n\n\u201cYes, you are. I\u2019m Jackie, taking care of Mr. Harj Singh. Please do the 12 lead.\u201d\n\n\u201cAwesome. Hey, Mr. Singh. Can I ask you a couple of questions?\u201d\n\nHarj looks at Dennis and nods 'yes'.\n\nDennis goes through the same routine as Alexa of confirming Harj\u2019s identity.\n\n\u201cOk, you are you. I am going to place 10 little sticky patches on you, Mr. Singh. One for each leg and arm and six on your chest. This test won\u2019t hurt, but I will need you to stay very still. Have you had one of these before?\u201d\n\n\u201cYes, about four years ago when they determined I had high blood pressure. I\u2019ve no idea if it showed anything.\u201d\n\n\u201cWell, if we do find anything today, Dr. Smythe will discuss that with you.\u201d\n\nDennis proceeds to place all the leads on Harj, and after a few minutes is ready to take the test.\n\n\u201cOk, this is where you need to stay still. Ready. Excellent.\u201d Dennis presses the record button and, a few seconds later, a pink 8 x 11 paper with multiple black lines is printed out. Dennis hits the print button a second time and gives the copy to Jackie. \u201cHere is the preliminary result for you to discuss with Dr. Smythe. I\u2019ll take the original with me for analysis by the cardiologist-on-call. If you have any questions, please call them.\u201d\n\n\u201cThanks, Dennis.\u201d\n\n\u201cOk, Mr. Singh. Looks like you\u2019ve had all your tests done. We will need to wait for some of the results, and then Dr. Smythe will come and talk to you and your wife. I\u2019m going to step out for a minute and get your wife to come in. Is that ok?\u201d\n\nHarj nods 'yes'.\n

Time: 22h30<\/h3>\nJackie approaches Dr. Smythe at the nursing station. \u201cHave you got a minute to look up the results of Mr. Singh in Trauma 1?\u201d\n\n\u201cYes, I was just about to check to see what\u2019s back.\u201d\n\nBoth Jackie and Dr. Smythe step closer to the computer screen. Dr. Smythe pulls up the X-ray first.\n\n\u201cThe chest X-ray looks clear, so does not look like he has ventricle dysfunction<\/a> or a low LVEF<\/a>. Heart is a bit enlarged. He may be developing heart failure or is on the cusp of doing so.\u201d\n\nNext Dr. Smythe pulls up the lab work. \u201cThe WBC are normal. Not really helpful, but at least we know there is no inflammation. HGB is normal. BUN and creatinine are higher than I would expect but within normal range. Ah, here is what I am looking for. The <\/a><\/strong>troponin is normal<\/a>, so no MI for Mr. Singh. All good news. You have his 12 lead, Jackie?\u201d\n\n\u201cYes, I don\u2019t see any depression or elevation in any of his leads, so, looking at the 12 lead with the trops, he appears to have unstable angina, not an MI.\u201d Jackie hands the 12 lead to Dr. Smythe.\n\n\u201cCompletely agree. UA not MI. Ok. Let\u2019s repeat and keep him until morning. But if everything stays the same and he has no chest pain, he can be discharged. I see he has no doctor on file. Is there a way we can have him followed?\"\n\n\u201cI will talk with social work in the morning. Maybe they can arrange a GP for him so he can be followed.\u201d\n\n\u201cThanks, I\u2019ll go talk to him and his wife.\u201d\n","rendered":"

Day: 0<\/h2>\n

Time: 22h30<\/h3>\n

Place: Emergency Room<\/h3>\n

Nurse Jackie, on the triage desk tonight, let\u2019s out a long sigh, and says to herself, \u201cBeen a quiet evening so far.\u201d Jackie has her back to the waiting room and is updating the census when she hears, \u201cExcuse me, can you help my husband? I think he\u2019s having a heart attack!\u201d<\/p>\n

Jackie immediately turns around and looks at the two people standing at the triage desk. She sees two middle-aged East Asian individuals: one, a woman who looks about to burst into tears and a man, quite overweight, hair a bit messed up, and rubbing his left shoulder.<\/p>\n

\u201cCan you say that again? Your husband is having chest pain?\u201d<\/p>\n

Priya, looking a bit exasperated and tired at the same time, says, \u201cYes, he thinks it\u2019s nothing but indigestion, but since dinner he has been rubbing his shoulder and complaining of not feeling well. He took some Tums but that didn\u2019t help. He blames my cooking, but we\u2019ve been married for over 25 years. If my cooking was a problem, he would be slimmer.\u201d<\/p>\n

Jackie looks at both of them again and nods. She quickly comes out from the triage desk and grabs a nearby wheelchair. \u201cMr\u2026?\u201d<\/p>\n

\u201cMy name is Harj Singh and I don\u2019t need a wheelchair.\u201d<\/p>\n

\u201cPlease have a seat, Mr. Singh, and let\u2019s humour your wife and me. It looks to me like you\u2019re having some difficulty breathing. You are rubbing your arm and upper chest, and you look a bit paler than I would expect.\u201d<\/p>\n

Harj plops down into the wheelchair with a huff, looking quite unhappy with the whole situation. Priya reaches down and squeezes his hand.<\/p>\n

Jackie squats down to talk directly to Harj and Priya. \u201cWe take chest pain very seriously, so a lot of things are going to happen real quick. I am going to take you back in behind my desk to a special room. We\u2019re going to take your blood pressure and other vitals and have a doctor look quickly at you. We\u2019ll probably give you some medications to see if we can relieve the pain in your arm and chest. Your wife can stay with you, as we\u2019ll need to understand more of how this started. But then I\u2019ll ask her to step away to the admitting desk to give them some information. Are you ready?\u201d<\/p>\n

Harj and Priya now both look quite scared, but nod affirmative.<\/p>\n

Jackie moves behind the wheelchair, rapidly pushes it to the acute side of the Emergency Room, and enters Trauma Room 1. As she enters the trauma room, she nods to two other emergency nurses who come over. \u201cHey, Jackie, anything we can do to help?\u201d<\/p>\n

\u201cYes, can you let Dr. Smythe know that we have a patient with chest pain in Trauma 1. Can you also get me ASA <\/a>and some nitrospray<\/a>. I\u2019ll also need someone to start an IV <\/a>on Mr. Singh.\u201d<\/p>\n

One of the nurses moves quickly over to the unit coordinator to page Dr. Smythe and the other nurse, Carrie, assists Jackie to get Mr. Singh onto the trauma room stretcher.<\/p>\n

\u201cOk, Mr. Singh. Carrie here is going to help you remove your shirt. She is also going to start an IV in your left arm, in case we need to give you some fluids. I am going to take your vital signs.<\/a>\u201d<\/p>\n

Jackie wraps the blood pressure cuff around Harj\u2019s right arm, places an SpO2<\/sub> probe on his left forefinger, and puts a temperature probe under his tongue. Carrie grabs the monitor leads and places five leads on Harj\u2019s chest. She turns the monitor on.<\/p>\n

Looking at the vital sign machine, Jackie records the vital signs onto the Emergency Record.<\/p>\n\n\n\n\n
Day: 0<\/strong><\/td>\nPulse Rate<\/strong><\/td>\nBlood Pressure<\/strong><\/td>\nRespiratory Rate<\/strong><\/td>\nTemperature<\/strong><\/td>\nO2 Saturation<\/strong><\/td>\n<\/tr>\n
Time: 22:00<\/strong><\/td>\n96<\/td>\n180\/90<\/td>\n28<\/td>\n36.5\u00b0C<\/td>\n95%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Looking up at the monitor, she notes that Harj is in normal sinus tachy with some ST depression noted on leads II and III.<\/a><\/p>\n

\u201cNow that is done, are you having pain in your chest?\u201d<\/p>\n

Harj nods ‘yes’.<\/p>\n

\u201cHave you had this type of pain before?\u201d<\/p>\n

Priya looks anxiously at her husband. Harj, looking down at his belly, says, \u201cYes, but only for a short time. When I sat down it went away.\u201d<\/p>\n

Priya looks horrified. \u201cYou never told me! What am I to do with you?\u201d<\/p>\n

\u201cIt\u2019s ok, Mrs. Singh. This is quite usual. Denial is quite common. Mr. Singh, if you were to rate your pain <\/a>on a scale of 1 to 10, with 1 being barely able to feel any discomfort and 10 being the worse pain you have ever felt, what would you say your pain is right now?\u201d<\/p>\n

\u201cIt\u2019s about 5 out of 10.\u201d<\/p>\n

\u201cRight, I am going to give you an aspirin and spray some medication under your tongue. It tastes terrible and may give you a bit of a headache as well. Do you have any drug allergies? What medications are you currently taking?\u201d<\/p>\n

Priya looks at Jackie. \u201cHe is on HCTZ<\/a>. Sorry, I can\u2019t say the whole name. One tablet in the morning for high blood pressure.\u201d<\/p>\n

Jackie looks at them both. \u201cDo you take any Viagra<\/a> or Cialis<\/a>?\u201d<\/p>\n

Both Harj and Priya look at each other and shake their heads ‘no’.<\/p>\n

\u201cThe reason I asked is that those drugs can cause a very low blood pressure with the medication I am going to spray under your tongue.\u201d<\/p>\n

Jackie hands Harj a small med cup with a tiny blue 81 mg ASA in the bottom of the cup.<\/p>\n

\u201cI want you to chew this aspirin. It will taste awful, so here is a cup of water to rinse and swallow after.\u201d<\/p>\n

Harj takes the ASA and chews the medication, making a sour looking face, and drinks all the water from the cup in one swallow.<\/p>\n

\u201cOk, I am going to now spray some medication under your tongue. Please open your mouth and put the tip of your tongue on the roof of your mouth.\u201d<\/p>\n

Harj does as he is told and Jackie sprays nitro<\/a> twice under his tongue. \u201cLet\u2019s give that a couple of minutes to see if that helps your chest pain.\u201d<\/p>\n

\u201cJackie, the IV is in Mr. Singh\u2019s left ACF<\/a>. I have NS running at 25 cc\/hour<\/a> on the pump right now. Are you ok?\u201d<\/p>\n

\u201cThanks, Carrie. I should be fine. Mr. Singh doesn\u2019t look critical right now. I will call if we need help. Can you cover the triage desk for a little bit while we get Mr. Singh settled?\u201d<\/p>\n

\u201cYes, no problem. I\u2019ve done that before. I\u2019ll call you if I need help. Then maybe we can switch?\u201d<\/p>\n

\u201cSure thing. Thanks.\u201d Jackie reaches over and pushes the NIBP button<\/a> again to see how Harj\u2019s blood pressure is after the nitro sprays. She then enters the number in the emergency record.<\/p>\n

\u201cGood evening, I\u2019m Dr. Smythe. Can you give me an update here, Jackie?\u201d<\/p>\n

Jackie looks up at the doctor who has entered the trauma room. \u201cHello, Dr. Smythe. This is Mr. and Mrs. Singh. Mr. Singh came in with a complaint of chest pain radiating to left arm and jaw. We have given him two sprays of nitro, 81 mg of ASA, and oxygen saturations are above 93%<\/a>, so I have not given him oxygen. I was just about to inquire as to his chest pain and call you about additional orders.\u201d<\/p>\n

\u201cThank you, Jackie. Mr. Singh, how do you feel right now?\u201d<\/p>\n

Harj looks up and sees a well-dressed, bow-tied traditional looking doctor in a short, white coat. \u201cI am doing ok right now. I think everyone is making a bigger deal about this than is necessary. I need to get to work in the morning or I don\u2019t get paid.\u201d<\/p>\n

\u201cLet\u2019s deal with one issue at a time here. Can you tell me about your chest pain?\u201d<\/p>\n

Harj rolls his eyes, then begins to explain that he had this type of chest pain a couple of weeks ago, but it went away when he rested in the cab of his truck. Today, after dinner, it came back. He took some antacids, but it did not go away.<\/p>\n

\u201cIt felt like dull heavy pressure, with some numbness to my left arm.\u201d<\/p>\n

Priya adds, \u201cHe complained of feeling tired, and I had to help him walk to the car, as he was so short of breath and tired. He also looks pale.\u201d<\/p>\n

\u201cDo you smoke, Mr. Singh?\u201d<\/p>\n

Pryia says, \u201cWay too much. At least a pack a day.\u201d<\/p>\n

\u201cOh, come on! I don\u2019t smoke that much.\u201d<\/p>\n

\u201cYes, you do. I see the empty packs in the recycling box.\u201d<\/p>\n

\u201cDo you drink alcohol?\u201d<\/p>\n

\u201cYes, I have a drink after work.\u201d<\/p>\n

\u201cMore like two or three drinks after work. Harj, they are trying to help you, not criticize you. Tell them the truth!\u201d<\/p>\n

\u201cOk, I have two to three drinks per evening of Crown Royal.\u201d<\/p>\n

Dr. Smythe and Jackie write the information down. \u201cThank you, Mr. Singh. What about your work? Is it stressful?\u201d<\/p>\n

\u201cNot really. I run a small trucking delivery company. Things have been tight, but not especially so.\u201d<\/p>\n

Priya rolls her eyes. \u201cWe are barely making ends meet. Everyday Harj is out fixing the truck. He is up at 5am and doesn\u2019t usually come home till after 6pm.\u201d<\/p>\n

\u201cThat sounds a bit stressful. Do you have any activities other than work, Mr. Singh?\u201d<\/p>\n

\u201cIf you are asking, do I exercise, no.\u201d<\/p>\n

\u201cRight, how would you describe your chest pain now?”<\/p>\n

\u201cA bit less than when I came in. Oh, right, you want a number. Three out of 10. The sprays helped, but it has really made my head ache.\u201d<\/p>\n

Dr. Symth looks at Jackie. \u201cHow long since the last spray of nitro?\u201d<\/p>\n

Jackie consults the emergency record. \u201cA little over five minutes.\u201d<\/p>\n

\u201cOk, give him two more sprays of nitro, and if the chest pain doesn\u2019t go away, try morphine, 1-2 mg IV, till the pain is gone. I\u2019ll write that down for you. Plus, let\u2019s get some lab work, including CBC,<\/a> lytes,<\/a> BUN,<\/a> creatinine<\/a>, Trops,<\/a> 12 lead,<\/a> and a portable chest X-ray<\/a>.\u201d<\/p>\n

Jackie nods her head and makes note of what Dr. Smythe has stated.<\/p>\n

Dr. Smythe moves over to the same side of bed that Priya is on. \u201cI\u2019m not positive that your husband is having a heart attack. We need to do some tests, then we will know more. I\u2019m going to keep him here until we have those results.\u201d<\/p>\n

\u201cAww, Doc,\u201d Harj says, \u201cYou are going to cost me money to do this.\u201d<\/p>\n

Pryia grabs his hand. \u201cBetter a day\u2019s pay than a dead husband.\u201d<\/p>\n

Harj rolls his eyes and leans back into his pillow with a sigh of exasperation.<\/p>\n

\u201cMrs. Singh, why don\u2019t you follow me out to the admitting desk so we can get all of your contact information, and then you can call any other family. Jackie will take good care of your husband.\u201d<\/p>\n

Dr. Smythe leads Priya out to the admitting desk and introduces her to the clerk there. \u201cYou can give your contact information to the clerk. When you\u2019re done, just go to the desk where you came in and ask to see your husband. They will guide you to him.\u201d<\/p>\n

Priya thanks Dr. Smythe.<\/p>\n

Dr. Smythe returns to the unit clerk\u2019s desk and asks her to have the lab and X-ray come to see Mr. Singh in Trauma 1.<\/p>\n

She looks up at him. \u201cJackie already called me to let me know that she put the order into the computer as stat. They should be coming shortly. Do you want to add anything?\u201d<\/p>\n

\u201cNo, that\u2019s a good start. Let\u2019s see what the results are and go from there. He may not need to be admitted if it\u2019s just angina.\u201d<\/p>\n

Time: 21h55<\/h3>\n

Jackie confirms with Mr. Singh that his chest pain is still three out of 10 and sprays two more doses of nitro under his tongue.<\/p>\n

Place: Medical Laboratory
\n<\/strong><\/h3>\n

Alexa, just about to leave the Emergency Department and head to the lab to drop off some specimens and restock her cart, looks down at her buzzing pager, and thinks, Stat lab work in Trauma 1. That takes precedence over going to the lab. Looks like my break will be a bit later than usual<\/em>.<\/p>\n

Turning around her white cart, Alexa walks quickly to Trauma 1.<\/p>\n

Entering Trauma 1, Alexa sees an overweight middle-aged East Asian male and Jackie, the nurse that is usually at the triage desk.<\/p>\n

\u201cHi, Jackie. I\u2019m here from the lab. You requested some stat blood work?\u201d<\/p>\n

Jackie turns around and smiles. \u201cHi, Alexa. Thank you for coming so quick. Yes, this is Mr. Harj Singh. We are investigating him for unstable angina, possible MI<\/a>.\u201d<\/p>\n

\u201cOk, do you have the labels?\u201d<\/p>\n

\u201cYes, they\u2019re over there on the printer.\u201d<\/p>\n

Alexa walks over to the label printer and pulls off three labels for Mr. Harj Singh.<\/p>\n

Walking back to Harj\u2019s bedside, Alexa begins the routine of checking identity. \u201cHi, Mr. Singh. My name is Alexa and I\u2019m going to draw some blood for testing. I need to ask you some questions to confirm that you are the right person and that the labels all match up.\u201d<\/p>\n

\u201cReally, here is my ID band. Is that not good enough?\u201d<\/p>\n

\u201cNo, we really want to make sure we are taking blood from the right patient, as many treatments are based on the results, and you would not want to receive the wrong treatment.\u201d<\/p>\n

\u201cAh, yes, you guessed right. I want no mistakes. Ask your questions.\u201d<\/p>\n

Alexa goes through the process of confirming name, date of birth, and Mr Singh\u2019s ID number.<\/p>\n

Once satisfied, she efficiently draws the blood<\/a> from Harj\u2019s right antecubital fossa<\/a>.<\/p>\n

\u201cAll done, Mr. Singh. Please hold pressure here for another couple of minutes. Jackie, I will take the blood back to the lab and you should have the results for the troponin very quickly.\u201d<\/p>\n

\u201cThanks, Alexa.\u201d<\/p>\n

\u201cOk, Mr. Singh, can you tell me how your chest pain is right now?<\/p>\n

Harj looks up at her. \u201cI think it\u2019s gone.\u201d<\/p>\n

\u201cThat\u2019s excellent. We\u2019ll do all of these tests and make sure nothing else is happening, but this is a good sign.\u201d<\/p>\n

Time: 22h10<\/h3>\n

Gurpreet checks the list of patient requests and sees that the top request is a portable chest X-ray<\/a> in Trauma 1.  Pulling up the patient data she sees that the patient was admitted with potential MI. \u201cOk,” she says to herself. “I can understand them not wanting to transport to the department. Looks like I will do this with the portable machine.\u201d<\/p>\n

Gurpreet pulls the requisition off the printer and heads straight out the department doors and down the stairs that lead directly to the Emergency Department. At the bottom of the stairs she pulls an imaging plate<\/a> out of the rack and places it in the rear door of the portable X-ray machine. Unplugging the machine, she pushes the portable down the hallway and navigates it through the chaos of people moving around in the Emergency Department into Trauma 1.<\/p>\n

\u201cHi, I\u2019m Gurpreet from Medrad here to do a chest X-ray on Mr. Singh.\u201d<\/p>\n

\u201cHi, Gurpreet. I\u2019m Jackie and this is Mr. Harj Singh.\u201d<\/p>\n

\u201cHello, Mr. Singh. Do you think you can sit straight up and have a very hard board behind you?\u201d<\/p>\n

\u201cI think so. Depends on how straight.\u201d Harj points at his belly as he says this.<\/p>\n

\u201cWe can work around it. Let\u2019s see.\u201d<\/p>\n

Both Jackie and Gurpreet help Harj to sit up in bed, and they place the hard cassette behind his back.<\/p>\n

Gurpreet moves to the end of the bed and looks at Mr. Singh. \u201cCan you move a little to your right, that\u2019s it. Hold right there.\u201d<\/p>\n

Gurpreet moves the machine into position. She pulls the tape measure out of the camera and confirms that it is the appropriate distance away. Looking at Mr. Singh she adjusts the technique settings for exposure. That should work on someone his size<\/em>, she thinks to herself. Pushing a button to bring up the positioning lighting, Gurpreet makes adjustments to capture the chest correctly.<\/p>\n

\u201cOk, ready to shoot.\u201d<\/p>\n

Jackie steps quickly out of the room as Gurpreet grabs the lead shield to cover her neck and chest and pulls the exposure button out as far as the cord goes. \u201cOk, Mr. Singh, take a deep breath and let it out. Ok, ready to shoot. Take a deep breath and hold it … X-ray! Trauma 1.\u201d<\/p>\n

Gurpreet presses the exposure button and the portable machine whines up and makes a clicking noise.<\/p>\n

\u201cOk, all clear, Mr. Singh. Great job. Let\u2019s get that hard cassette out.\u201d<\/p>\n

Both Jackie and Gurpreet remove the cassette and reposition Harj. \u201cHow is that?\u201d<\/p>\n

\u201cI am good, thank you.\u201d<\/p>\n

\u201cThanks, Gurpreet. How long till I can see the results?\u201d<\/p>\n

\u201cI\u2019ll run it through now and should have it on the system in less than 10 minutes.\u201d<\/p>\n

\u201cExcellent.\u201d<\/p>\n

Gurpreet pushes the machine out and places it back in its special niche. Grabbing the exposed cassette she heads back to the department to process the chest X-ray of Mr. Singh.<\/p>\n

Just as Gurpreet is leaving, Dennis from Cardiology pushes his cart in. \u201cI have a req for a 12 lead<\/a> for one Mr. H. Singh with complaint of chest pain. Am I in the right place?\u201d<\/p>\n

\u201cYes, you are. I\u2019m Jackie, taking care of Mr. Harj Singh. Please do the 12 lead.\u201d<\/p>\n

\u201cAwesome. Hey, Mr. Singh. Can I ask you a couple of questions?\u201d<\/p>\n

Harj looks at Dennis and nods ‘yes’.<\/p>\n

Dennis goes through the same routine as Alexa of confirming Harj\u2019s identity.<\/p>\n

\u201cOk, you are you. I am going to place 10 little sticky patches on you, Mr. Singh. One for each leg and arm and six on your chest. This test won\u2019t hurt, but I will need you to stay very still. Have you had one of these before?\u201d<\/p>\n

\u201cYes, about four years ago when they determined I had high blood pressure. I\u2019ve no idea if it showed anything.\u201d<\/p>\n

\u201cWell, if we do find anything today, Dr. Smythe will discuss that with you.\u201d<\/p>\n

Dennis proceeds to place all the leads on Harj, and after a few minutes is ready to take the test.<\/p>\n

\u201cOk, this is where you need to stay still. Ready. Excellent.\u201d Dennis presses the record button and, a few seconds later, a pink 8 x 11 paper with multiple black lines is printed out. Dennis hits the print button a second time and gives the copy to Jackie. \u201cHere is the preliminary result for you to discuss with Dr. Smythe. I\u2019ll take the original with me for analysis by the cardiologist-on-call. If you have any questions, please call them.\u201d<\/p>\n

\u201cThanks, Dennis.\u201d<\/p>\n

\u201cOk, Mr. Singh. Looks like you\u2019ve had all your tests done. We will need to wait for some of the results, and then Dr. Smythe will come and talk to you and your wife. I\u2019m going to step out for a minute and get your wife to come in. Is that ok?\u201d<\/p>\n

Harj nods ‘yes’.<\/p>\n

Time: 22h30<\/h3>\n

Jackie approaches Dr. Smythe at the nursing station. \u201cHave you got a minute to look up the results of Mr. Singh in Trauma 1?\u201d<\/p>\n

\u201cYes, I was just about to check to see what\u2019s back.\u201d<\/p>\n

Both Jackie and Dr. Smythe step closer to the computer screen. Dr. Smythe pulls up the X-ray first.<\/p>\n

\u201cThe chest X-ray looks clear, so does not look like he has ventricle dysfunction<\/a> or a low LVEF<\/a>. Heart is a bit enlarged. He may be developing heart failure or is on the cusp of doing so.\u201d<\/p>\n

Next Dr. Smythe pulls up the lab work. \u201cThe WBC are normal. Not really helpful, but at least we know there is no inflammation. HGB is normal. BUN and creatinine are higher than I would expect but within normal range. Ah, here is what I am looking for. The <\/a><\/strong>troponin is normal<\/a>, so no MI for Mr. Singh. All good news. You have his 12 lead, Jackie?\u201d<\/p>\n

\u201cYes, I don\u2019t see any depression or elevation in any of his leads, so, looking at the 12 lead with the trops, he appears to have unstable angina, not an MI.\u201d Jackie hands the 12 lead to Dr. Smythe.<\/p>\n

\u201cCompletely agree. UA not MI. Ok. Let\u2019s repeat and keep him until morning. But if everything stays the same and he has no chest pain, he can be discharged. I see he has no doctor on file. Is there a way we can have him followed?”<\/p>\n

\u201cI will talk with social work in the morning. Maybe they can arrange a GP for him so he can be followed.\u201d<\/p>\n

\u201cThanks, I\u2019ll go talk to him and his wife.\u201d<\/p>\n","protected":false},"author":103,"menu_order":4,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":["glynda-rees","rob-kruger","janet-morrison"],"pb_section_license":"cc-by-sa"},"chapter-type":[],"contributor":[116],"license":[54],"class_list":["post-552","chapter","type-chapter","status-publish","hentry","contributor-janet-morrison","license-cc-by-sa"],"part":547,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/chapters\/552","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/wp\/v2\/users\/103"}],"version-history":[{"count":0,"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/chapters\/552\/revisions"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/parts\/547"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/chapters\/552\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/wp\/v2\/media?parent=552"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/pressbooks\/v2\/chapter-type?post=552"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/wp\/v2\/contributor?post=552"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/dcbiol2200\/wp-json\/wp\/v2\/license?post=552"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}