Case Study #2: Pneumonia

Day 1: Emergency Room

Day: 1
Time: 02h00
Place: Emergency Room

Jason decides to take another set of vital signs:

Day: 1 Pulse Rate Blood Pressure Respiratory Rate Temperature O2 Saturation
Time: 02h00 86 160/90 22 36.5°C 90%
Time: 02h30

“Dr. Singh, here are the spirometry results and ABG on Erin Johns.”

“Thanks.” Dr. Singh reviews the results and comes to the same conclusions as Matt and Jason. “Let’s look at her chest X-ray.”

Dr. Singh pulls up the X-ray film onto the computer and both lean in to view the black and white picture. Jason looks at the picture and then at Dr. Singh, thinking to himself that it looks like a normal X-ray except that the lungs look a bit long.

Dr. Singh, sighs, “Okay, the X-ray shows a small amount of infiltrates at the bases and your typical COPD hyperinflation. Nothing that I would consider abnormal itself, but when we consider the ABG and the spirometry all together, I would like to keep her overnight to see if she is going to get better or going to get worse. If it’s pneumonia, she will get worse overnight and the next day. If it’s just the cool weather we are having and nothing infective, she should get a bit better with some care and attention. What do you think?”

“Matt and I were having the same discussion. I am pretty sure I can find a bay for her to stay in. Question is, will she want to stay?”

“I’ll go talk to her.”

“Hello, Mrs. Johns, my name is Dr. Amir Singh. I am one of the many people here taking care of you.”

“Not sure about taking care of me. First I’ve seen of you.”

Dr. Singh smiles. “So true, I have been more in the shadows than caring for you directly like Jason here. Both Jason and I have reviewed your tests and we believe you should stay overnight with us. I don’t think it’s serious, and if you are able to get a reasonable sleep, a few more puffs of the meds I have ordered along with some oxygen, you may feel better in the morning.”

“I am feeling better. Not perfect. Can I have a bed? Can my dog visit me? Will someone call my son?”

Dr. Singh smiles. “Yes to all. I will call your son and let him know, and Jason here will find you one of our finest beds in Emergency.”

“Thank you.”

Dr. Singh then nods to both Erin and Jason and walks over to where a nurse is gesturing for him at Bed 3.

Jason bends down to be at eye level with Erin and says, “Give me a couple of minutes and I will find you a more private location.”

Erin nods and smiles. She grabs Jason’s hand and pats it kindly, like so many older ladies do with Jason.

After a discussion with the charge nurse and getting housekeeping to clean an area from a recent discharge, Jason is able to move Erin into the last stretcher bed farthest from the nursing station and the doors. It’s the most private location they have and a coveted location for staff to take their breaks.

“This should be a lot better for you. You need to let me know if you need to use the washroom as I will get another oxygen tank on wheels for you to use when you are up.”

“Thank you. What about my son and Trixie?”

“Dr. Singh and I updated Thomas. He is not going to come in tonight but will in the morning. He says not to worry about Trixie. Thomas said he was going to give her a bath and a meal and they were going to chill with some movies.”

“Oh she really needs a bath. Been feeling awful not to be able to do even that small task. Trixie likes to watch Mad Men. That Mr. Draper is such a scamp!”

“Ok, Mrs. Johns. One more set of vitals and then you can sleep. If you need anything please push the call button.”

Day: 1 Pulse Rate Blood Pressure Respiratory Rate Temperature O2 Saturation
Time: 02h00 86 160/90 22 36.5°C 90%
Day: 1
Time: 07h00
Place: Emergency Room

Dr. Notley is reviewing the list of patients to see this morning when he is approached by the charge nurse with a list of overnight patients that potentially could be sent home if everything is well.

“Can you look at these patients first? Let me know which ones can be sent home. Mrs. Erin Johns in the far room appears to be a little worse. We may need to find her a bed.”

Dr. Notley nods “I’ll see Mrs. Johns quickly and then take a look at the potential discharges. I trust your judgement so starting drawing up the paperwork on those patients so that when I agree we can move them quickly.”

Dr. Notley pulls up Erin Johns’s electronic record: Exacerbation of COPD, on 2 LPM nasal prongs, ABG shows higher than normal CO2 and drop in PaO2 with maybe something on the CXR.

Dr. Notley walks quickly down the hall to the last stretcher in the row of 20. Seeing the curtain partially open, he announces himself, “Good morning, I’m Dr. Notley.”

Jackie, the nurse taking care of Erin, waves him in.

“Hello Jackie, how are you doing?”

“Doing good, thanks. Right now, Mrs. Johns is not doing as well as expected. I was at the triage desk yesterday when she came in. This morning, I have increased her O2 to 5 LPM and I’m asking the RT to come by and assess her for face mask or Optiflow. I am not sure which option is best.

Her sats have stayed 90–91% on 5 LPM, work of breathing appears increased, and her breath sounds have expiratory wheezes in upper fields with coarse crackles in lower fields.”

“That is a bit disappointing. How are you feeling Mrs. Johns?”

Erin looks at Dr. Notley and thinks to herself, He looks exactly how a doctor should look, nice grey hair, pressed lab coat and a stethoscope around his neck.

“I feel tired. Can’t catch breath. Can’t get out. Of bed. Had to use. Bedside commode. What is happening. To me?”

“Well, Mrs. Johns, that is a very good question. We anticipated that you would get better with additional puffers and a good night’s sleep. Obviously that has not happened. I am going to listen to your chest and then order some tests to help find out why you’re not feeling yourself. I expect that we’re going to have to start you on antibiotics and admit you to the medical floor for additional treatment.”

“I don’t want to stay here.”

“Mrs Johns, I would like you to stay. I know it’s challenging being away from family…”

“My dog, Trixie.”

“Yes our pets are family. You have a long term condition called COPD. I suspect that you also have pneumonia as well. If you go home, you will likely get worse.”

“You mean die!?”

“Yes, that could happen. I don’t ask my patients to stay without a good reason. Do you trust me?”

Mrs. Johns looks down and twists the white wrinkled bed sheet in her hands, “You do look. Like a good doctor. Ok. I trust you.”

“Thank you. I am going to listen to your chest now and then write some orders for tests, and talk with the medical team to get you a bed as soon as possible. Your stay may not be long with us if we can get the right treatment.” Dr. Notley lifts his stethoscope off his neck, places the ear pieces in his ears and gently places the bell on Erin’s chest. He listens methodically,  anteriorly and posteriorly.

“Thank you Mrs. Johns. Jackie and I are going to step out now and see a couple of other patients but we will be back.”

Jackie and Dr. Notley step through the curtain and make their way to an alcove to have a more private discussion.

“What do you think Dr. Notley?”

“I agree with you Jackie, Mrs. Johns looks a lot worse. Her chest sounds very congested and wheezy. O2 requirements are going up. I expect she has community acquired pneumonia. I would like to order another CXR, CBC, ABG, and a sputum sample. I’ll see if the lab has the gram stain on the earlier sputum sample which may help guide us. I will also order some antibiotics but will check with pharmacy to make sure I order the correct one. I will admit her and let the medical admit team know they have a new patient. Anything else you need?”

“That sounds good. I will have the RT get the ABG now so we can get the right O2 therapy.”

“Excellent. Your other two patients are on my discharge list. How are they doing?”

“Both are excellent. No complaints and both are already dressed and have called for a ride. They both need scripts for the meds that were ordered last night. Once you have seen them, I will move them to the waiting room so we can get the areas clean and ready for a couple of the hallway patients that need a spot.”

“Okay. Let me quickly see them. I’ll write the scripts and discharge orders so you can move them. Thank you.”

Dr. Notley heads over to Beds 18 and 19 to talk to the patients ready for discharge. Jackie waits for a bit in case he needs something and then moves off to the nursing station to page the RT.

Time: 07h30

Jackie sees Alexa come into the unit and quickly walks over to her.

“Hi Alexa, do you have a minute to check a patient with me and draw an ABG?”

“Oh, hi Jackie. Just give me a minute to finish running this blood gas and gather some stuff. I can meet you at the bedside. Which patient?”

“It’s Mrs. Johns in the back room.”

Alexa nods and rapidly walks over to the ABG machine to run the blood gas. Jackie turns and goes to Mrs. Johns’s stretcher.

“Mrs. Johns, Alexa, a respiratory therapist will be here shortly to assess you and draw a blood gas which will help us help you.”

“Ok. Had one. Yesterday. I think”

“Yes that is correct, and here is Alexa.”

Alexa places her hand lightly on Erin’s wrist to feel for a pulse and introduces herself. “Hi Mrs. Johns, I am Alexa, a respiratory therapist. I am going to listen to your chest, poke your wrist here for a blood test, and depending on the result, make some adjustments to your oxygen therapy before you head upstairs to the ward. Are you okay with that plan?”

“Yes.”

“You appear quite short of breath so I won’t ask you to move around a whole lot.”

Alexa checks the oxygen flow, the position of the nasal prongs, and listens to Erin’s chest. Taking her right wrist, Alexa performs the Allen test.

“Everything looks good. I am going to go ahead and do the test now.”

Alexa efficiently obtains the ABG. Erin does not even flinch and is just lying back in her bed breathing rapidly.

“You did great Mrs. Johns. I am going to have Jackie hold your wrist for a few more minutes while I go and run this sample through a special machine.”

Jackie comes over and holds Erin’s wrist firmly to prevent bruising. Alexa moves off quickly to the blood gas machine.

A few minutes later Alexa comes back. She takes a look at Erin’s wrist and puts a light pressure dressing on it. She then shows Jackie the ABG results.

Day: 1 pH O2 CO2 HCO3 SaO2
Time: 08h30 7.3 65 52 27 89

“Thanks Alexa, the CO2 is about normal for Mrs. Johns with the COPD but the oxygen levels are much lower which is a bit concerning.”

“I agree, I think I will place her on Optiflow right now, and when she goes up to the floor ask whoever is covering up there to take another look. I think we can follow just with monitoring her on the pulse oximeter and not require another blood gas until maybe tomorrow.”

“Sounds good to me.”

Jackie leans down and explains the plan to Erin who weakly nods her head.

Alexa moves off quickly to gather the Optiflow equipment and returns a couple minutes later. She sets up the humidifier and places the high flow nasal prongs in Erin’s nose. Making some adjustments to the flow, Alexa leans in. “How does that feel Mrs. Johns?”

“It’s a bit better. Thanks” Looking up at the SaO2 displayed on the screen, both Jackie and Alexa can see the number increase to 93%.

Alexa listens to Erin’s breath sounds and finds no real changes.

“Ok Jackie, I think she is fine right now. Dr. Notley ordered a CXR and I think we should do it portably. I will call the department to ask them to do so. I think the transport to x-ray and back may be too much activity at this time.”

“I agree. I can call them if you wish?”

“No, I’ve got this. You probably have other things to do this morning.” Alexa indicates the two patients that need to be moved to the waiting room and have their discharge forms completed.

“Yeah. It is pretty busy but not too bad. Almost feels slow given how it was the last couple of days.”

Alexa smiles and moves towards the nursing station to call the X-ray department. Jackie walks over to the two patients waiting in chairs for their paperwork to be completed so they can leave.

Alexa Calls X-ray Department

“Hi, this is Alexa. I am the RT in the Emergency department. I think you have a req for a CXR for Mrs. Erin Johns?”

“Just a minute, let me check.”

Alexa hums a Drake tune to herself as she waits. Smiling to herself, she remembers his concert from last week.

“Yes, we have the req for Mrs. Johns. I was about to call for a porter for her as we are ready to take her picture.”

“We would prefer that it is done portably. I have just placed her on high flow and she is really short of breath. I am concerned that if we move her that she may deteriorate or worse.”

“Now we don’t want ‘or worse.’ I will mark that she is unstable and will ask the tech to perform the X-ray portably.”

“Awesome. Thank you!”­­

Alexa hangs up the phone and moves off to find Jackie to let her know.

Place: Medical Radiography

Serge looks at Emily, the unit coordinator for X-ray and frowns. “She can’t come to the department?”

“Yes, that’s correct. The RT says she is unstable and is concerned that she won’t do well being moved about.”

“Okay, I hope there is someone to help me out down there.”

“I am sure there is, Serge. Your back will be fine. You might want to think about a different sport to do on your days off. I saw the YouTube video of your rugby game that you posted. That game is violent. You took some pretty good hits.”

Serge smiles. “Yeah. My partner says the same thing, yet he comes to every game and cheers us on. I think he gets a kick out of seeing me being flattened on the field!”

Emily laughs. “I also like to see you flattened. Your expression after being run over is one of pure confusion, as in ‘How could this happen to me?’”

Serge laughs. “Okay, I can only take so much ribbing here. I’m off to Emergency. Sharon and Preeti are the only ones in the department right now. They are in the back helping out in Room 2 with a chest tube insertion. You can page me if anything comes in. They will probably be busy for another 30 minutes or so.”

Emily nods her head and goes back to the computer.

Serge heads quickly out the doors and takes the back stairs to the Emergency Department. In the alcove by the back stairs in Emergency is the portable X-ray machine. He grabs an unexposed plate and places it in the cassette bin on the back of the machine. He then checks the charge and pre-sets a chest technique of 85 kvp and 5 mAs before unplugging the machine. He navigates the X-ray machine to Erin’s stretcher. Looking at the requisition for the reason for the exam, he thinks to himself, “SOB. Not much of a history.” Driving the X-ray machine to the end of the bed, he pulls out the X-ray tube to point towards his client.

“Good morning, Mrs. Johns.” While reaching to read her name band, he continues, “My name is Serge and I am going to take a picture of your chest today.” Serge notes the large nasal prong Optiflow and then looks at the SaO2 on the screen and sees the number in the low 90s. Ok, that is not bad, but not great, he thinks. I can see why they asked for a portable.

Erin weakly opens her eyes to see a very large man with a jet black beard holding what looks to be a rectangular metal board. Looks more like a lumberjack than anything else, she notes. What is he going to do to me?

Erin turns her head a bit more towards Serge. “What?”

Serge smiles broadly “Mrs. Johns, I am going to take an X-ray of your chest. Dr. Notley has requested this test to help us help you.”

“Ok, that makes a bit more sense. I am feeling. Very tired so. What do you need. Me to do?”

“Oh nothing. You just relax there in bed. Who is your nurse today?”

“Jackie.”

“You are kidding right? Nurse Jackie? Like the TV show?”

Just then Jackie comes up behind Serge and rests a hand lightly on his elbow. “That’s right, just like the TV show. Do you want my autograph?”

Serge quickly turns around. “I was just kidding!” Jackie looks at him sternly for about 10 seconds then breaks into a smile. “You cannot believe how often I hear that comment. I wish that damn show never was on TV.”

Serge visibly relaxes. “Can you help me position Mrs. Johns so we can get the best picture possible?”

“Would be happy to do so. Thanks for doing this portable. I am not sure that she would have tolerated going to the department.”

“We are a bit short-staffed today so it’s a bit of a stretch for us, but yes, I can see why you asked.”

Turning his attention back to Mrs. Johns, he says to her, “We are going to get you sitting up straight in your stretcher. Looks like you’re high up enough on the bed that we don’t need to boost you.”

Serge and Jackie position Erin into high fowlers and place the X-ray plate behind her back. “This is a hard board, but it won’t be for too long.” From the side of the stretcher, Serge reaches around Mrs. Johns to make sure there is enough of the Imaging Plate (IP) on both sides of her and above her shoulders. “Try your best to hold still.” Serge walks back to the portable X-ray machine to adjust his pre-set technique to 90 kVp @ 3.2 mAs to hopefully compensate for her SOB. That should give a faster exposure, he thinks. Meanwhile, Mrs. Johns wiggles from the discomfort of the plate, and the IP slips down from where Serge had placed it. He does not notice.

“Okay Mrs. Johns, I’m going to take that X-ray now. Hold still.” Serge reaches for the lead apron hanging on the portable machine. He opens the collimation wide and adjusts the tube head to match his IP. Speaking very loudly, he calls out, “X-ray, Bed 3!” On cue, Jackie and all the other personnel scatter. Turning back towards Mrs. Johns, he says, “Breathe in. Mrs. Johns, take a breath in!” Serge watches her chest fall and rise, and takes the X-ray on what he hopes is inspiration. “X-ray clear!” He pulls Mrs. Johns forward on his own, and slips out his plate. “I’ll sit you back a little. Let me know when…” He starts to bring her head down until she nods.

“Thanks Mrs. Johns. I am all done now. Dr. Notley should have the result in a few minutes. Thanks, Nurse Jackie.”

Jackie scowls at Serge and lightly punches him in the arm. “Be careful now. I saw that YouTube video of you playing rugby. I could see me cheering-on the opposing team.”

Serge rolls his eyes. “Who hasn’t seen that video? It’s going to haunt me for a long time.”

“No longer than the Nurse Jackie show for me.”

Serge smiles and backs the portable X-ray machine away from the bedside and navigates it back to the alcove. He plugs it in and readies it for the next use.

Opening the back stairwell door, he take the stairs two at a time back to the department.

Place: Medical Laboratory

Alexa, who was the lab tech on duty yesterday, checks the list of patients she was just handed by the unit coordinator. Wow, I got Emergency again, she notes to herself. This is either going to be a good day or not. Looking through the list, she sees the familiar name of Erin Johns. “I wonder how she is doing? I think I will go see her first.”

Alexa pushes her white cart to the elevator and makes her way to the Emergency Department. Checking in at the nurses station she confirms that Erin Johns is still in Emergency and that she is in the back area.

Alexa proceeds to Erin’s bedside and looks behind the curtain to see the elderly woman sleeping. Moving towards her, she touches Erin’s hand only to see her startled.

“What now? Who are you? Where am I?”

“It’s okay Mrs. Johns. My name is Alexa and you are in the hospital. Dr. Notley ordered some lab tests for you and I am here to draw them.”

“Oh, you are the girl from yesterday.”

“That is correct.”

“You were so gentle; what do I need to do?”

“Just relax, Mrs. Johns. I need to check your ID band and ask you some quick questions.”

Alexa checks the ID band against the requisition and the blood tube labels and sees that everything is correct.

“Can you tell me your birth date?”

Erin recites her birth date easily to Alexa.

“Excellent. Can you tell me your middle name?”

“That must be a trick question. I don’t have a middle name.”

“Yes. I need to confirm that you are who you are and not someone else. This makes sure that the test is done on the right person.”

Erin nods her head. Alexa wraps a tourniquet around Erin’s right upper arm. She assesses the brachial vein and sees it stand out after a few seconds. Nodding to herself, she reaches back into her cart and gathers the correct tubes. “This is going to feel like a pinch. Are you ready?” Erin just nods. Alexa quickly inserts the needle into the vein and fills each of the tubes. Releasing the tourniquet she places a cotton swab on Erin’s puncture wound. “Please hold here, Mrs. Johns. I just need to label your tubes.” After labeling the tubes, Alexa checks the site and sees no further bleeding. Alexa places a small round band-aid on the site. “All good. You okay?”

“Yes I am fine for being locked up in this place.”

Alexa nods and turns to cart and leaves Mrs. Johns.

Time: 09h30

Dr. Notley approaches Jackie. “Okay, the medical team has accepted Erin Johns. Can you get her ready to go to the 7th floor? She will be under Dr. Honicutt’s team.”

“She is pretty well ready to go. I need to fill out her transfer assessment information and gather any belongings. She has been asking when she can get out of this noisy place.”

Dr. Notley smiles and turns to the unit coordinator. “Can you ask for a porter to help Jackie take Erin Johns to the floor please?”

“Glen will be back from Diagnostics shortly and he knows to check with Jackie next about the transfer.”

“Excellent. Okay, I am off to the triage desk to see who will fill that stretcher.”

“Thanks.” Looking at the unit coordinator, Jackie asks, “Can you hand me up one of those transfer assessment forms please?”

“Sure thing.”

Jackie takes the form handed to her, reviews the notes and Erin’s chart, and fills it out quickly, remembering to include the son Thomas’ cell phone number and Erin’s concern about her dog, Trixie. “I will have to include that she wants her dog to visit as well. Not sure about the policy up on the 7th floor with dogs. Anyway they will figure it out. Oh, almost forgot—better find Alexa the RT so she can get the O2 tank.”

Jackie walks back to Erin’s stretcher to find Alexa already with a portable tank and setting it up.

“I was just going to page you to see if you knew about the transfer.”

“A little bird by the name of Glen let me know that this may be happening. I will go up with Glen and transfer my notes over to the floor RT so they are aware to check in on Mrs. Johns often.”

Jackie smiles. “Glen always seems to know when things are happening. He’s the one who showed me the video with Serge taking that hit.”

“Mrs. Johns, in a few minutes, Glen and Alexa are going to take you up to the 7th floor. You will be in a semi-private room, meaning that you will have one other person with you. I will phone your son so he is aware of your move.”

“Can my dog visit?”

“I am not sure; you will need to ask the nurses up there.”

Erin looks a bit disappointed and sinks back into her pillow.

Just then Glen comes around the corner “All ready to go?”

“Yes, here is the transfer assessment, and Alexa will report to the floor RT. Let them know all the latest results are in the system. Here is her bag of meds. I have started the antibiotic, and it’s infusing on the pump.”

“Okay, sounds good. Leave her to us, she is in good hands.”

“Take care Mrs. Johns.” Jackie watches as Glen pushes the stretcher out of the Emergency Room towards the patient elevator. She notes to herself, “She does not look happy but does look slightly better with some oxygen on. Ok, I wonder who will be taking her place?”

Jackie turns around and heads to the nursing station to find out who will be filling the stretcher.

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Day 1: Emergency Room by BCIT is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License, except where otherwise noted.

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