Case Study #2: Pneumonia
Day 0: Emergency Room
Place: Emergency Room Triage
Sitting back in her chair, Jackie sighs. “Wow, this has been a long shift. I’m exhausted.”
Looking up from the desk, she sees an old green Ford truck stop in front of the Emergency Room. From the passenger door, an elderly lady slowly emerges. Reaching back into the truck, she pulls out a very small dog and slowly places it on the ground.
The older lady makes her way slowly to the doors, with the dog trailing her on a leash. Once she is inside the doors, Jackie notes that the woman displays pursed lip breathing, has a slight blue tinge to her lips and a very slow gait.
Finally making it to the triage desk, the lady leans against the desk and sighs loudly.
Jackie comes out from behind the desk and moves a wheelchair close to Erin for her to sit in.
“Hi, my name is Jackie and I’m the triage nurse today. How can I help you?”
“Thank you. My name. Erin. I feel awful. Can’t catch. My breath.”
Jackie pulls the blood pressure and pulse oximetry machine close to Erin and wraps the cuff around her right arm. She presses a button and the cuff inflates. On Erin’s left index finger she places a pulse oximeter.
After about 30 seconds, the machine beeps and displays the following vital signs:
|Day: 0||Pulse Rate||Blood Pressure||Respiratory Rate||Temperature||O2 Saturation|
|Time: 18h00||96||180/90||28||36.5° C||85%|
Grabbing a clipboard with an emergency assessment record on it, Jackie fills out the initial vital signs.
Referring to the Triage and Acuity Scale along with the vital signs, Jackie grades Erin’s condition as “Triage Level III – Urgent”.
A tall middle-aged man in workman’s clothes approaches the triage desk. “How is my Mom doing?” asks Thomas.
“I think it would be best if Mrs. Johns stays with us awhile and has a doctor take a look at her. I will make arrangements for a spot for her to stay once we get her admission paperwork done. Can you and your Mom answer a few questions from Denise, the clerk who is just to the left of my desk?”
Denise, the admission clerk, comes over and introduces herself to Erin.
“Good evening. My name is Denise.”
“My name is. Erin. This is my son. Thomas,” Erin states breathlessly.
“Ok. Thomas, can you wheel your Mom close to my desk so I can input her information into the computer, please? That way we can get her a space in the ER quickly and have a doctor see her as well.”
Thomas pushes the wheelchair over to the admissions desk.
“Do you have your Care Card with you?” asks Denise.
Erin hands over her Care Card to Denise, who rapidly inputs the information into the system.
“I see, Mrs. Johns, that you were at a clinic last week. Is this correct?”
Erin nods ‘yes’. Thomas explains: “They changed her puffers and said to come back if there was any problem.”
Denise nods her head. “Make sure you tell the nurses that.”
Denise then asks, “Do you see anyone regularly at the clinic?”
“No. I see whoever is available. They change so often.”
Looking up at Thomas, Denise asks, “Can I have your contact information, Thomas, in case we need to contact you?”
Thomas recites his cell phone number and tells Denise that he currently lives with his Mom, due to a complicated divorce that has left him a bit depressed and short of cash.
Denise nods and inputs the contact information into the computer.
“Well, that is all I need right now. I have called for a porter and they will move you to a spot where the doctor can see you.”
Denise watches as the porter comes up to both Thomas and Erin and begins pushing the wheelchair through the doors into the back area of the Emergency Ward.
Denise shakes her head slightly and wiggles her nose. She thinks to herself, “That dog needs a bath. Poor thing.”
“Is this where. You are. Going to leave. Me. It’s a hallway!” Erin looks up at the porter pleadingly.
The porter looks at her. “You will need to wait here till there is a better spot for you,” and he walks away.
Erin pulls Trixie closer to her as she sits in the wheelchair. Thomas looks around at the chaos and sees people moving from curtained area to curtained area, all dressed alike in light blue scrubs. No one makes eye contact or even acknowledges them as the new arrivals.
Just as he is thinking this to himself, he feels a presence behind him. Turning around, he sees another nurse dressed in light blue holding a clipboard.
“Are you Mrs. Johns and her son, Thomas?”
Both nod affirmatively.
“My name is Jason. I’ve just come on shift. I see the triage nurse started your chart and that you have been admitted. What I need to do now is listen to your chest and ask you some questions. Is that ok?”
Jason watches both of them nod ‘yes’.
“Ok, then. Thomas, would you mind taking the dog outside so I can assess your mother?”
Thomas reaches down and gently extracts Trixie from Erin.
“Can you come get me after you’re done?” asks Erin.
Thomas: “Mom, I’ll walk Trixie and then put her in the truck. I have some biscuits that I can give her and she should be perfectly fine there.”
Thomas cradles the small dog, who begins to whimper quietly, and strides out through the doors to the emergency exit.
Jason pulls a chair closer to Erin. “I am going to ask you a few questions. This helps us to help you. Do you feel up to answering a few questions?”
“When did you begin to feel short of breath?”
“About a week. Ago. I went. Clinic. Gave me new puffers. Seemed to help. Today. Walking Trixie. Cold out. Really short of breath. Called Thomas. Brought me here.”
Jason writes the information directly into the second page of the nursing record.
“The clinic notes indicate you have COPD. Is this correct?”
“Do you have any other conditions?”
“No.” Erin smiles weakly. “Otherwise. Healthy.”
“Ok. That is enough right now. Let’s take your vital signs, and then I’m going to listen to your lungs and heart.”
Jason pulls the vital sign machine close to the wheelchair, attaches the BP cuff and the pulse oximeter, and presses the button.
As the cuff inflates, Jason looks carefully at Erin. He notes that her airway is patent and her breathing is rapid at 28/minute and appears shallow, with some nasal flaring.
The blood pressure cuff dings and the result appears on the screen.
“Ok Mrs. Johns, your blood pressure is higher than I would expect. Is this normal for you?”
Erin leans forward and peers closely at the numbers, “I think so. Top number. 150 to. 170. Normally.”
|Day: 0||Pulse Rate||Blood Pressure||Respiratory Rate||Temperature||O2 Saturation|
|Time: 20h00||92||170/90||26||36.4° C||84%|
Jason nods. “Your oxygen saturation is a bit low, so I am going to put you on a little oxygen. Is that ok with you?”
Jason reaches over to draw in a cart from the hallway. He pulls out a set of nasal prongs and attaches them to an oxygen tank fitted at the back of the wheelchair. He thinks to himself and then sets the flow at 2 LPM.
“Let’s see if that helps with your shortness of breath. I’m now going to listen to your heart and lungs. I know we are in the hallway and I’ll do my best to not expose you. Are you ok with me examining you?”
“Yes. Not happy. In hallway.”
“I can understand that, but we’re very busy and I have no other place to give you. I hope this will only be for a couple of hours.”
Jason then carefully slips his stethoscope between Erin’s clothes and skin. Closing his eyes, he moves the stethoscope systematically first to the anterior chest then posterior chest. After listening, he quickly examines her abdomen and extremities.
“Ok, Mrs. Johns. I’m done right now. I see your oxygen levels appear to be a bit higher. Are you feeling a little less short of breath?”
“Yes, I feel a bit better.”
“Great! I am going to find the doctor and see what the plan will be for you. If you need any help, just wave your arms.”
Erin nods that she understands. Looking around, she shivers slightly at being sick and so exposed in the hallway. She watches Jason move towards the nursing station where there are two people who look like doctors. She thinks to herself, “They look so young. How can they be doctors? I’m stuck in a hallway, can’t believe all the money we pay for taxes and this is the best they can do for me. When Thomas comes back, I’ll ask him to take me and Trixie home. This is ridiculous.”
Jason looks at the various people huddled around the nursing station.
He shakes his head slightly and mumbles, “Yeah, shift change for everyone.”
He walks up to Dr. Singh, whom he is most familiar with. As he approaches he hears Dr. Singh announce, “I’ll take the back rooms and the hallway patients. Stan, can you take the triage and trauma? I did that yesterday, and with that patient dying in the trauma room, I still have to sign off the chart and have a discussion with the coroner.”
Stan looks up at his peer. “Ok, but if it gets really busy, we’ll need to call someone in or you will need to help.”
Dr. Singh sighs. “If you need help, I will stay.”
Dr. Singh moves off to check the computer for emergency admissions and to start planning his shift.
Jason moves up beside him. “Can I interrupt?”
“Sure thing, Jason. What’s up?
Trying to keep to SBAR, Jason says, “I just came on shift as well. New patient, Mrs. Johns, 72 years old, in Hallway B. Exacerbation of COPD, maybe pneumonia, no other medical history, quite short of breath with low sats. I placed her on 2 LPM prongs with some relief and better sats. Breath sounds are quite quiet to the lower fields and she has a slight wheeze in the upper fields. She’s stable right now but I need some orders, please.”
“Ok, Jason. I agree that she’s stable right now, but with a big potential to deteriorate. I will follow the COPD protocol and write orders for a chest X-ray, some labs, puffers, spirometry, and an ABG. Let’s hold off on antibiotics till we have a firmer picture of pneumonia. I don’t want to overreact and prescribe something she doesn’t need right now. With her diagnosis and potentially frequent antibiotic use, we could set her up for a superbug. How does that sound?”
“I agree, and thank you. I’ll get the RT for the ABG and see if Medrad can do the X-ray portably.”
Dr. Singh pulls out a doctor’s order sheet. Jason places a sticker with Erin Johns’s identification on the top right corner.
Jason takes the orders from Dr. Singh and goes over to the unit clerk, Sheila.
Sheila looks at him with raised eyebrows. “I just got here, so please don’t tell me this is a long order set! My commute was terrible and daycare was late opening up. I already feel behind before I’ve even started.”
Jason smiles. “Aww, Sheila. I hate when my day starts like that. I once had to bring little Jim in to work when my daycare was late as well. Cathy picked him up a half hour into the shift. The orders are really short, as you would expect from Dr. Singh. Just what you need, no extras. Since you are settling in, do you want me to enter them into the computer?”
“That would be awesome!! I see Dr. Greg’s admitted a patient to 7B and the order set for that patient is seven pages. I would rather get started on that set, if you don’t mind.”
“No problem.” Jason moves away from the nursing station and signs on to a computer located just a few feet from Erin.
He types in all the information and generates the requisitions for the orders Dr. Singh wrote: CBC, lytes, BUN, creatinine, spirometry, and a portable chest X-ray, and medications as per COPD protocol.
Jason quietly moves towards Erin and notes that she is sleeping in the chair.
“Wow, I wonder when she last had a good sleep.”Jason gently touches her arm to wake her and updates her on her tests. He tells her that Dr. Singh will come by in a little bit, after the tests are done, to check on her.
Erin nods and then closes her eyes.
Place: Medical Laboratory
Alexa has just started her shift. Smiling inwardly, she thinks, “This is my third shift by myself after orientation. Can’t believe it. School does a good job of preparing you for the job, but nothing can prepare you for the work. It’s so busy. My feet already hurt.”
Straightening her scrub top, she leans over and double-checks her cart to make sure she has enough supplies to last the majority of the shift.
The lab supervisor approaches her. “Emergency is really busy right now. Would you mind going down there first before heading to the rest of the hospital? Sheila, the clerk down there, says there are about 20 lab reqs waiting.”
“Ok, I haven’t been there since I was a student.”
“No worries. James is already down there and he can help you out. He thoroughly enjoys the atmosphere of the Emergency.”
Alexa pushes her cart out of the lab area and heads to the elevator that goes to Emergency. She pushes the button for the Emergency floor and watches the buttons slowly creep towards that floor. Exiting, she pushes her cart up to the emergency staff doors, and taking a deep breath she pushes the button. As soon as the doors open, she sways back from the noise and the smells and the overwhelming sense of chaos.
“Oh my. Yep, school did not prepare me for this. Wow.”
Navigating her cart through the Emergency Department, she thinks to herself, “It’s just like driving in rush hour in a foreign country. There are rules but no one sticks to the lines.”
She quickly finds herself at the nursing station and moves towards the desk area where all the reqs are waiting. She notes that James has taken all the stat ones, as there is not one in the pile. Looking through reqs, she notes that they are all pretty similar and all the reqs have close to the same time on them.
“Ok, let’s start with this one,” she says as she places Erin Johns’s req on the top of her board. Looking at the req, she pulls out the appropriate lab tubes and labels them with Erin Johns’ stickers.
That done, she looks up. A frown creases her forehead, and she mumbles, “Hallway B. Where the heck is that?”
Jason, walking by, hears Alexa mumble and stops. “Hi, I’m Jason and Hallway B is my assignment. Who are you looking for?”
Alexa, looking somewhat sheepish, says, “I didn’t think anyone would hear me mumble in this noise.”
“It’s not so noisy and you do get used to it.”
“I’m looking for Erin Johns.”
“Erin is my patient. Let’s walk over here and down this corridor. I’ll introduce you. I haven’t seen you before. Are you new?”
“Yes, this is my third shift by myself after orientation. I’ve mainly been in the lab department or on the medical floors. I was in Emergency for some of my final preceptorship.”
“Excellent. This is a great place to work. Busy, but the people are knowledgeable and quite caring.”
As they move down the hallway, Alexa sees an elderly lady, still in her normal clothes and with a light blanket wrapped around her shoulders, sleeping in a wheelchair.
“Yes. That is Erin Johns.”
Jason moves confidently up to Erin and lightly touches her on the arm. Alexa notes that Erin’s eyes open quickly and they appear sharp and not withdrawn, like some of the patients she has seen.
“Mrs. Johns, this is Alexa, one of our lab technicians. She’s here to take some blood from you. Is that ok?
Erin nods ‘yes’.
Alexa moves her cart closer. Looking at the req and then at Mrs. Johns, she says, “Can you tell me your name?”
“Excellent, thank you.” Alexa checks the identification band on Erin’s right wrist against the information on the requisition. Satisfied, she gathers the tubes, double-checks them, and picks up the venipuncture equipment and tourniquet. Following the World Health Organization guidelines, Alexa prepares to take the required blood specimens.
Alexa first asks Erin to roll her sleeve up a bit more. Carefully putting the tourniquet around Erin’s right upper arm, Alexa then swabs her inner antecubital space.
“Ok, this will pinch a bit.”
Carefully sliding the needle under the skin, Alexa quickly finds the vein and pushes the first of three tubes into the vacutainer.
Once all the tubes are full, Alexa shakes them slowly and carefully to mix the blood and the anticoagulant. After that, she carefully places the tubes in the holder in the front of her cart.
“I’m all done, Mrs. Johns. I hope you feel better soon.”
Alexa moves away and heads towards the nursing station. She looks down at the next req on her list and notes that it’s not a hallway but a number. Looking around, she quickly finds number 12 and heads towards the next patient.
Place: Medical Radiography
Gurpreet checks the list of patients requisitions that need to be done. Looking at the list, she sees there are a number of emergency patients and floor patients. No reqs are marked as stat.
“Ok, looks like we need a porter.”
Glen looks across the lobby from where he is sitting. “What’s that, Gurpreet? Do you need me?”
“Sorry, Glen, didn’t see you there. Yes, can you go pick up Mrs. Erin Johns from Hallway B in Emergency, please?”
“Yes, no problem.”
Glen pulls himself out of the chair and strides through the double doors of the Radiology Department. Looking quickly up and down the hallway, Glen makes his way down the back stairs to the Emergency Department.
Glen has been working in the hospital for about 15 years and knows every short cut there is. Taking the stairs two at a time, he arrives at a little used doorway into Hallway B of the Emergency Department.
Walking up to the nursing station at the far end of the hallway, he looks at Sheila, the unit clerk. “Hi ya, Sheila.”
“Oh, hi Glen. What can I do for you?”
“Oi, how about dinner?”
“That’s not what I meant!” Sheila smiles at her boyfriend and winks at him.
“I’m here to escort Mrs. Erin Johns to the Radiology Department for a picture.”
Sheila looks at her assignment list and finds that Jason is the nurse. “Ok, Jason is caring for her. And there he is talking with Mrs. Johns.”
“Thanks. See you after work?”
“I’m done at seven. Come down here when you’re finished. We can share a bus seat home.”
Glen smiles and walks towards Erin and Jason.
“Hi, my name is Glen and I’ve been asked to escort Mrs. Johns here to the X-ray Department.”
Jason frowns. “Can’t that be done portably?”
Glen shakes his head. “Not my call. Gurpreet asked me to escort her to the department.”
Jason leans down and explains to Erin that she needs a chest X-ray to help them figure out why she is short of breath.
Erin, looking a bit more tired, says, “I’ve had quite a few of those. I’d be glad to get out of this hallway. It’s so noisy.”
Glen grabs the back of the wheelchair, quickly turns her around and points the chair out the door. Striding to the elevator, Glen recaps for Erin the weather outside, the hockey game, and recent city events. Erin sits in her chair and pretends to listen.
Glen and Erin roll through the doors of the Radiology Department to see Gurpreet standing at the desk.
“Here is Mrs. Erin Johns, from Hallway B in the Emergency Department.”
“Thank you, Glen. Can you place her in Room 2, please? I’ll be right behind you.”
Place: Emergency, Hallway B
“When will I get my results?”
Glen looks at Erin. “I’m not the one to ask, I’ll let Sheila know you are back, so the doctor and Jason can look at your picture.”
Glen walks quickly away to the nursing station to inform Sheila that the chest X-ray is completed.
Erin looks up and down the hallway and sees less activity and some empty stretcher bays.
“I do hope I can get a bed to lie down in,” she thinks to herself. “My backside is getting sore.”
Without realizing it, Erin closes her eyes. Suddenly she feels a touch on her hand. Startled, she gives a little shout.
“Oh oh oh, it’s ok. My name is Matt. I had no intention of scaring you. Wow. Really sorry, Mrs. Johns.”
“It’s ok. I didn’t realize I had fallen asleep.”
“I’m a respiratory therapist and a couple of tests have been ordered for you. One is spirometry, which I think you have had before, from the results in your chart, and the second one is a blood gas.”
“Spirometry is the blowing test, right?”
“Yes, that’s the one. Shall we do that one first?”
Matt opens a small plastic bag to retrieve a freshly sterilized kit tube with a gauge on it. He quickly describes what he wants Erin to do.
“Mrs. Johns, I’m going to ask you to take a deep breath and then blow it out as hard as you can through this tube. We’re going to do this three times to make sure we get an accurate measurement.”
Erin sits a bit straighter in her wheelchair and nods. “I’ll try my best.”
Matt hands Erin the device. “Good. Ok, take a deep breath, then blow through the tube.”
Erin does as instructed, three times. After each time, Jason records the results on the requisition for spirometry.
“Ok, that is now done. You did a great job, Mrs. Johns.”
Erin nods her head and smiles slightly.
“Next, I need to do an Arterial Blood Gas or ABG, so I must draw a small sample of blood from your wrist. This is a bit more uncomfortable than having your lab work done.”
Erin looks up questioningly. “Is it necessary? I had a blood gas done before and it really hurt!”
“I’ll try my best to not hurt you, but it is uncomfortable. Which hand do you use the most?”
“I am right-handed.”
Matt gently grabs Erin’s left hand and bends her elbow 90 degrees. He then performs the Allen test.
“Ok, ok, everything looks good, Mrs. Johns.”
Matt then rubs an alcohol swab vigorously across Mrs. Johns’ wrist. Then he waves his hand back and forth to disperse the smell.
“I need you to relax and stay still while I do this, ok?”
Erin nods nervously.
Matt, holding the syringe at a 45 degree angle, slips the needle under Erin’s skin. Quickly the syringe fills with red fluid. Matt then withdraws the syringe and holds a gauze over the site.
“That wasn’t too bad. You are very good at this.”
“I’ve had a bit of practice, Mrs. Johns.” While holding pressure on her left wrist, Matt deftly removes the needle from the sample and caps the syringe. After a couple of minutes, he asks Erin to hold pressure but not to peek and not to let go until he comes back.
Taking the sample, Matt goes to the back area of the Emergency Department and runs the sample through the blood gas machine. The machine quickly prints out the result.
Matt goes back to Erin.
“Ok, let’s look under the gauze.”
Matt see no bleeding but notes a small bruise at the puncture site. He places a small gauze over the site and wraps a small dressing right around Erin’s wrist.
“Please leave this dressing on. We can take it off later tonight, but I want to make sure you don’t get left with a big bruise.”
Matt steps away to find Jason and show him the results from spirometry and the arterial blood gas.
Matt finds Jason at the computer in the nursing station.
“Hi Jason, I have the results from spirometry and blood gases for Mrs. Johns.”
Jason, looks up, smiles and says, “Ok, anything special?”
“Spirometry shows a decrease in vital capacity from what was taken at the clinic a couple of months ago, with her FEV1 / FVC ratio < 0.7. That’s not surprising, given that she is back here. The ABG shows a rise in CO2 and just normal PaO2 on 2 LPM oxygen. She is a bit compromised right now. I took a listen to her chest a little while ago. She sounds typically COPD-like with nothing I didn’t expect.”
“Ok. Are the results on the clipboard?”
“Yes, and I hope you don’t mind that I entered the ABG in her chart as well.”
“You are awesome, I will go find Dr. Singh when I am done here and see what he would like to do, but my guess is she is staying the night.”