Case Study #3: Unstable Angina (UA)

Emergency Room

Day: 0
Time: 22h30
Place: Emergency Room

Nurse Jackie, on the triage desk tonight, let’s out a long sigh, and says to herself, “Been a quiet evening so far.” Jackie has her back to the waiting room and is updating the census when she hears, “Excuse me, can you help my husband? I think he’s having a heart attack!”

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.

“Can you say that again? Your husband is having chest pain?”

Priya, looking a bit exasperated and tired at the same time, says, “Yes, he thinks it’s 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’t help. He blames my cooking, but we’ve been married for over 25 years. If my cooking was a problem, he would be slimmer.”

Jackie looks at both of them again and nods. She quickly comes out from the triage desk and grabs a nearby wheelchair. “Mr…?”

“My name is Harj Singh and I don’t need a wheelchair.”

“Please have a seat, Mr. Singh, and let’s humour your wife and me. It looks to me like you’re having some difficulty breathing. You are rubbing your arm and upper chest, and you look a bit paler than I would expect.”

Harj plops down into the wheelchair with a huff, looking quite unhappy with the whole situation. Priya reaches down and squeezes his hand.

Jackie squats down to talk directly to Harj and Priya. “We 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’re going to take your blood pressure and other vitals and have a doctor look quickly at you. We’ll 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’ll need to understand more of how this started. But then I’ll ask her to step away to the admitting desk to give them some information. Are you ready?”

Harj and Priya now both look quite scared, but nod affirmative.

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. “Hey, Jackie, anything we can do to help?”

“Yes, can you let Dr. Smythe know that we have a patient with chest pain in Trauma 1. Can you also get me ASA and some nitrospray. I’ll also need someone to start an IV on Mr. Singh.”

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.

“Ok, 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.

Jackie wraps the blood pressure cuff around Harj’s right arm, places an SpO2 probe on his left forefinger, and puts a temperature probe under his tongue. Carrie grabs the monitor leads and places five leads on Harj’s chest. She turns the monitor on.

Looking at the vital sign machine, Jackie records the vital signs onto the Emergency Record.

Day: 0 Pulse Rate Blood Pressure Respiratory Rate Temperature O2 Saturation
Time: 22:00 96 180/90 28 36.5°C 95%

Looking up at the monitor, she notes that Harj is in normal sinus tachy with some ST depression noted on leads II and III.

“Now that is done, are you having pain in your chest?”

Harj nods ‘yes’.

“Have you had this type of pain before?”

Priya looks anxiously at her husband. Harj, looking down at his belly, says, “Yes, but only for a short time. When I sat down it went away.”

Priya looks horrified. “You never told me! What am I to do with you?”

“It’s ok, Mrs. Singh. This is quite usual. Denial is quite common. Mr. Singh, if you were to rate your pain 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?”

“It’s about 5 out of 10.”

“Right, 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?”

Priya looks at Jackie. “He is on HCTZ. Sorry, I can’t say the whole name. One tablet in the morning for high blood pressure.”

Jackie looks at them both. “Do you take any Viagra or Cialis?”

Both Harj and Priya look at each other and shake their heads ‘no’.

“The 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.”

Jackie hands Harj a small med cup with a tiny blue 81 mg ASA in the bottom of the cup.

“I want you to chew this aspirin. It will taste awful, so here is a cup of water to rinse and swallow after.”

Harj takes the ASA and chews the medication, making a sour looking face, and drinks all the water from the cup in one swallow.

“Ok, 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.”

Harj does as he is told and Jackie sprays nitro twice under his tongue. “Let’s give that a couple of minutes to see if that helps your chest pain.”

“Jackie, the IV is in Mr. Singh’s left ACF. I have NS running at 25 cc/hour on the pump right now. Are you ok?”

“Thanks, Carrie. I should be fine. Mr. Singh doesn’t 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?”

“Yes, no problem. I’ve done that before. I’ll call you if I need help. Then maybe we can switch?”

“Sure thing. Thanks.” Jackie reaches over and pushes the NIBP button again to see how Harj’s blood pressure is after the nitro sprays. She then enters the number in the emergency record.

“Good evening, I’m Dr. Smythe. Can you give me an update here, Jackie?”

Jackie looks up at the doctor who has entered the trauma room. “Hello, 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%, so I have not given him oxygen. I was just about to inquire as to his chest pain and call you about additional orders.”

“Thank you, Jackie. Mr. Singh, how do you feel right now?”

Harj looks up and sees a well-dressed, bow-tied traditional looking doctor in a short, white coat. “I 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’t get paid.”

“Let’s deal with one issue at a time here. Can you tell me about your chest pain?”

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.

“It felt like dull heavy pressure, with some numbness to my left arm.”

Priya adds, “He 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.”

“Do you smoke, Mr. Singh?”

Pryia says, “Way too much. At least a pack a day.”

“Oh, come on! I don’t smoke that much.”

“Yes, you do. I see the empty packs in the recycling box.”

“Do you drink alcohol?”

“Yes, I have a drink after work.”

“More like two or three drinks after work. Harj, they are trying to help you, not criticize you. Tell them the truth!”

“Ok, I have two to three drinks per evening of Crown Royal.”

Dr. Smythe and Jackie write the information down. “Thank you, Mr. Singh. What about your work? Is it stressful?”

“Not really. I run a small trucking delivery company. Things have been tight, but not especially so.”

Priya rolls her eyes. “We are barely making ends meet. Everyday Harj is out fixing the truck. He is up at 5am and doesn’t usually come home till after 6pm.”

“That sounds a bit stressful. Do you have any activities other than work, Mr. Singh?”

“If you are asking, do I exercise, no.”

“Right, how would you describe your chest pain now?”

“A 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.”

Dr. Symth looks at Jackie. “How long since the last spray of nitro?”

Jackie consults the emergency record. “A little over five minutes.”

“Ok, give him two more sprays of nitro, and if the chest pain doesn’t go away, try morphine, 1-2 mg IV, till the pain is gone. I’ll write that down for you. Plus, let’s get some lab work, including CBC, lytes, BUN, creatinine, Trops, 12 lead, and a portable chest X-ray.”

Jackie nods her head and makes note of what Dr. Smythe has stated.

Dr. Smythe moves over to the same side of bed that Priya is on. “I’m not positive that your husband is having a heart attack. We need to do some tests, then we will know more. I’m going to keep him here until we have those results.”

“Aww, Doc,” Harj says, “You are going to cost me money to do this.”

Pryia grabs his hand. “Better a day’s pay than a dead husband.”

Harj rolls his eyes and leans back into his pillow with a sigh of exasperation.

“Mrs. Singh, why don’t 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.”

Dr. Smythe leads Priya out to the admitting desk and introduces her to the clerk there. “You can give your contact information to the clerk. When you’re done, just go to the desk where you came in and ask to see your husband. They will guide you to him.”

Priya thanks Dr. Smythe.

Dr. Smythe returns to the unit clerk’s desk and asks her to have the lab and X-ray come to see Mr. Singh in Trauma 1.

She looks up at him. “Jackie 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?”

“No, that’s a good start. Let’s see what the results are and go from there. He may not need to be admitted if it’s just angina.”

Time: 21h55

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.

Place: Medical Laboratory

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.

Turning around her white cart, Alexa walks quickly to Trauma 1.

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

“Hi, Jackie. I’m here from the lab. You requested some stat blood work?”

Jackie turns around and smiles. “Hi, Alexa. Thank you for coming so quick. Yes, this is Mr. Harj Singh. We are investigating him for unstable angina, possible MI.”

“Ok, do you have the labels?”

“Yes, they’re over there on the printer.”

Alexa walks over to the label printer and pulls off three labels for Mr. Harj Singh.

Walking back to Harj’s bedside, Alexa begins the routine of checking identity. “Hi, Mr. Singh. My name is Alexa and I’m 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.”

“Really, here is my ID band. Is that not good enough?”

“No, 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.”

“Ah, yes, you guessed right. I want no mistakes. Ask your questions.”

Alexa goes through the process of confirming name, date of birth, and Mr Singh’s ID number.

Once satisfied, she efficiently draws the blood from Harj’s right antecubital fossa.

“All 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.”

“Thanks, Alexa.”

“Ok, Mr. Singh, can you tell me how your chest pain is right now?

Harj looks up at her. “I think it’s gone.”

“That’s excellent. We’ll do all of these tests and make sure nothing else is happening, but this is a good sign.”

Time: 22h10

Gurpreet checks the list of patient requests and sees that the top request is a portable chest X-ray in Trauma 1.  Pulling up the patient data she sees that the patient was admitted with potential MI. “Ok,” 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.”

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 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.

“Hi, I’m Gurpreet from Medrad here to do a chest X-ray on Mr. Singh.”

“Hi, Gurpreet. I’m Jackie and this is Mr. Harj Singh.”

“Hello, Mr. Singh. Do you think you can sit straight up and have a very hard board behind you?”

“I think so. Depends on how straight.” Harj points at his belly as he says this.

“We can work around it. Let’s see.”

Both Jackie and Gurpreet help Harj to sit up in bed, and they place the hard cassette behind his back.

Gurpreet moves to the end of the bed and looks at Mr. Singh. “Can you move a little to your right, that’s it. Hold right there.”

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, she thinks to herself. Pushing a button to bring up the positioning lighting, Gurpreet makes adjustments to capture the chest correctly.

“Ok, ready to shoot.”

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. “Ok, 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.”

Gurpreet presses the exposure button and the portable machine whines up and makes a clicking noise.

“Ok, all clear, Mr. Singh. Great job. Let’s get that hard cassette out.”

Both Jackie and Gurpreet remove the cassette and reposition Harj. “How is that?”

“I am good, thank you.”

“Thanks, Gurpreet. How long till I can see the results?”

“I’ll run it through now and should have it on the system in less than 10 minutes.”

“Excellent.”

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.

Just as Gurpreet is leaving, Dennis from Cardiology pushes his cart in. “I have a req for a 12 lead for one Mr. H. Singh with complaint of chest pain. Am I in the right place?”

“Yes, you are. I’m Jackie, taking care of Mr. Harj Singh. Please do the 12 lead.”

“Awesome. Hey, Mr. Singh. Can I ask you a couple of questions?”

Harj looks at Dennis and nods ‘yes’.

Dennis goes through the same routine as Alexa of confirming Harj’s identity.

“Ok, 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’t hurt, but I will need you to stay very still. Have you had one of these before?”

“Yes, about four years ago when they determined I had high blood pressure. I’ve no idea if it showed anything.”

“Well, if we do find anything today, Dr. Smythe will discuss that with you.”

Dennis proceeds to place all the leads on Harj, and after a few minutes is ready to take the test.

“Ok, this is where you need to stay still. Ready. Excellent.” 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. “Here is the preliminary result for you to discuss with Dr. Smythe. I’ll take the original with me for analysis by the cardiologist-on-call. If you have any questions, please call them.”

“Thanks, Dennis.”

“Ok, Mr. Singh. Looks like you’ve 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’m going to step out for a minute and get your wife to come in. Is that ok?”

Harj nods ‘yes’.

Time: 22h30

Jackie approaches Dr. Smythe at the nursing station. “Have you got a minute to look up the results of Mr. Singh in Trauma 1?”

“Yes, I was just about to check to see what’s back.”

Both Jackie and Dr. Smythe step closer to the computer screen. Dr. Smythe pulls up the X-ray first.

“The chest X-ray looks clear, so does not look like he has ventricle dysfunction or a low LVEF. Heart is a bit enlarged. He may be developing heart failure or is on the cusp of doing so.”

Next Dr. Smythe pulls up the lab work. “The 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 troponin is normal, so no MI for Mr. Singh. All good news. You have his 12 lead, Jackie?”

“Yes, I don’t 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.” Jackie hands the 12 lead to Dr. Smythe.

“Completely agree. UA not MI. Ok. Let’s 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?”

“I will talk with social work in the morning. Maybe they can arrange a GP for him so he can be followed.”

“Thanks, I’ll go talk to him and his wife.”

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