Case Study #6: Sepsis
Place: Emergency Room
“Hello James and Zac,” greets the triage nurse, Jackie. “Is this the patient you called about?”
“Hi, Jackie. Yes, it is,” James says. “BP is a little low. HR and RR are elevated. He looks septic to us. We have given him most of a liter of saline. Here is his chart from Sleepy Hollow. I need to finish my charting up before handing that off.”
“Sounds good. Please take him to the back room. They are set up for you there. The trauma rooms are busy with two victims from an MVC.”
Zac and James steer the stretcher through the double doors and down the long hallway to one of the back rooms, to find Dr. Pierce standing and talking with another nurse.
“Dr. Pierce, how are you doing?”
“I am well, James. Is this the patient from the care home?”
“Yes, this is George Thomas, 82 year old male with what Zac and I think is sepsis from UTI.”
James then delivers his report to Dr. Pierce along with the information from the care facility and the information that he and Zac gathered.
“Awesome report. Thanks, James. Well, let’s get him on our bed and to our monitor.”
Working together, all four health professionals move George from the ambulance stretcher to the emergency stretcher.
“I’m going to wait until he’s on your monitor before Zac and I leave, if that’s ok.”
“Sure thing. My name is Jim and I am one of the new Emergency nurses. Just give me a minute to get everything set up and ensure that George is safe.”
Jim quickly gets George on the monitor and presses the NIBP cuff. The two paramedics and Jim watch the monitor closely to see the displayed vital signs.
HR: sinus tachy at 110; RR 28; SpO2: 93%; BP: 98/64
|Day: 0||Pulse Rate||Blood Pressure||Respiratory Rate||Temperature||O2 Saturation|
“Thanks, Jim. That looks like what we got in the field. I just need to record these and sign the sheet and the charting is all yours.” James completes the ambulance form and hands it off to Jim and Dr. Pierce.
Jim moves closer to George and completes his primary assessment. Dr. Pierce stares at the monitor for a bit, and then steps to the other side of the bed and listens to George’s heart and breath sounds. “All right, Jim. What do you think?” asks the doctor.
“From the ambulance report, Mr. Thomas was being treated for UTI. Became increasingly neurologically challenged over the last couple of days, till today found unresponsive. Looking at vital signs, he meets all the criteria for SIRS. So I believe he has sepsis. The larger question, given his CNS changes, is does he have severe sepsis?”
“Completely agree about the sepsis. Let’s wait on the severe sepsis until we have given him more fluid, as I think he is still dry. If he does not respond to fluid, then I believe it may be severe sepsis. I’ll start the sepsis protocol. Do we have a weight on Mr. Thomas?”
Jim looks through the photocopied chart from Sleepy Hollow. “Ok, two months ago it was documented that he was 91.2 kg.”
“Guidelines state lactate and another liter of fluid. Start another IV, draw a lactate, blood cultures and give one liter of NS. Mr. Thomas should have a foley and urine spec sent as well. I’ll complete the rest of the orders and arrange for him to have a chest X-ray also as he has a few basilar crackles. And I need to know if this is pneumonia as that will change my antibiotic choices. I think I’ll see if someone is around from infectious diseases or the clinical pharmacist can assist me with antibiotic choices. Cultures first, then antibiotics.”
“Sounds good,” says Jim. “I’ll get that done right now.” Jim quickly gathers the equipment to start the IV and draw the lab work that Dr. Pierce has ordered. After the lab work is drawn and labelled, Jim starts the IV and places a pressure bag around it to infuse it quickly under 15 minutes. Calling to the front desk, he has the porter collect the blood samples for delivery to the lab. Next, Jim inserts a #16 foley catheter and collects a small amount of concentrated, not normal smelling, urine. He places this into a collection container and places it in the fridge for pickup by the lab.
Jim thinks to himself, Liter is almost in. Let’s check to see how he’s doing.
“Mr. Thomas. George. Open your eyes.”
George’s eyes flutter open and closed. A low groan emerges from his lips and he spontaneously moves all of his limbs.
A bit better than he was on arrival, but still not really awake. May need a bit more fluid, Jim thinks.
Jim documents the new CNS findings, checks the monitor, and records the latest vital signs, which have not really changed much. He listens to George’s chest and does not hear any increase in crackles or other sounds. He notes that urine output has not increased.
Dr. Pierce approaches Jim, who is finishing up his charting and readying himself to head off shift.
“Jim, have you seen the latest lactate?”
“Yes, it’s 4.1 and I’m wondering if you would like to give him another liter as his urine output has not increased. He perked up after that first liter we gave him. Other blood work is back. WBC are 22, HGB is 110, and other stuff is pretty well normal.”
“Ok, let’s give another liter,” instructs Dr. Pierce. “When is the next lactate due?”
“21:00. Jason is taking over for me and I’ll be sure to remind him.”
A few minutes later, Jason walks in and sits down beside Jim. The two nurses huddle together and Jim delivers his report on George Thomas.
“Thanks, Jim. Are you back tomorrow?” asks Jason.
“Yes. I have asked to be back here. If so, that will make reporting a bit easier for you.”
“Sounds good. See you in the morning.” Jason hears a whirring sound of heavy machinery coming closer and looks over his shoulder. I bet that’s for Mr. Thomas, he thinks.
Gurpreet pushes the portable X-ray machine right up beside Jason. “Hi, I’m Gurpreet and I have a req for Mr. George Thomas. Portable chest X-ray with differential diagnosis of pneumonia.”
“Hi, Gurpreet. I’m Jason and George is one of my patients this evening. He’s not very awake and is probably not going to sit up for you. Is it possible to do this supine?”
“Yes, but not a great picture that way and the radiologist prefers upright. We do what we can.”
Gurpreet moves to the bedside and checks on George. “My name is Gurpreet. I just need to double check who you are and then I’m going to place a very hard board behind your back and take a picture of your chest.”
No response from George.
Gurpreet looks at the requisition and compares it with the information on the ID band on George’s left wrist. “Jason, can you confirm George’s identity for me?”
“Yes, this is George Thomas.” Jason goes on to read out the birth date and medical plan number.
“Ok, we are good to go.”
Gurpreet returns to the portable X-ray and withdraws a large board from the rear hidden compartment. Slipping the board into a special plastic bag, she returns to the bedside. With Jason’s assistance, they both lean George forward and place the X-ray board behind his back.
Gurpreet maneuvers the X-ray machine into position at the end of the stretcher. She turns on a light on the camera head and adjusts the aperture for George’s chest size. Using the built-in tape measure, Gurpreet checks to make sure the X-ray is the proper distance away. Satisfied that everything is correct, Gurpreet nods and grabs a lead apron from the stanchion of the X-ray machine. She announces, “X-ray ready in Back Room 1.”
“Stand clear, X-ray exposing.” Gurpreet then presses a button which starts a whirring sound ending with a dull click.
“Ok, all done.” Gurpreet hangs up the lead apron on the stanchion and moves to the bedside to help Jason remove the board and reposition George.
Gurpreet then backs the portable X-ray machine out.
At the X-ray desk at the rear of the nursing station, Gurpreet places the exposed cassette into the scanner and enters the information from the requisition. A few seconds later, George’s image appears on the screen. Gurpreet looks the image over to ensure it is not overexposed and that all the thoracic fields are on the screen. Not a great film, being supine, she thinks. Will have to probably repeat when he can sit up. Gurpreet presses a sequence of buttons and releases the X-ray for viewing with notations that it’s a supine film.
Once done, she double checks that the portable machine is ready for the next patient. “All right, then, back to the department to see what’s next,” she says to herself.
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. 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.
Navigating her cart through the Emergency Department, she quickly finds herself at the nursing station and moves towards the desk area where all the requisitions are waiting. She notes that someone has taken all the stat ones as there are none in the pile. Looking through the requisitions, she notes that they are all pretty similar and all the reqs have close to the same time on them.
Let’s start with this one, she thinks. A frown creases her forehead, and she mumbles, “Back Room 1. Where the heck is that?”
Jason, walking by, hears Alexa mumble and stops. “Hi, I’m Jason and Back Room 1 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 George Thomas.”
“He’s my patient. Let’s walk over here and down this corridor.”
Jason moves confidently up to George and lightly touches him on the arm. Alexa notes that George opens his eyes briefly and then closes them.
“George, this is Alexa, one of our lab technicians. She is here to take some blood from you. Is that ok?”
No response from George.
“I don’t think he will mind. He does wake up vigorously at times, so I’ll stay and hold his arm in case he does.”
Alexa moves her cart closer. She looks at the req and then at George’s ID tag.
“Jason, can you confirm that this is George Thomas?”
“Yes, I can confirm.”
“Excellent, thank you.” Satisfied, she gathers the tubes, double checks them and picks up the venipuncture equipment and tourniquet.
“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 vacu-container holder.
Once all tubes are full, Alexa slowly and carefully shakes them to mix the blood and the anticoagulant. After that, she carefully places the tubes in the holder in the front of her cart.
“Thanks for your help, Jason.”
“No problem. I’ll probably see you in a couple of hours for the next lactate.”
“I believe so. I am covering down here all this week.”
Alexa moves away and heads towards the nursing station. She looks down at the next req on her list and notes it’s not a hallway but a number. Looking around, she quickly finds number 12 and heads towards the next patient.
Jason looks at his charting and the interim results from the lab work and X-ray.
He thinks, Ok, lactate is unchanged, other lab work is really ok. Urine analysis shows bacteria present, but not the type. He’s waking up, but not quickly by any stretch. Urine output better, still not on oxygen, so probably no pneumonia. I wonder about another 500 cc or even a liter of fluid.
As Jason is considering all the data, Dr. Smythe comes by. “So, Jason, how are you and George Thomas getting along?”
“Good evening, Dr. Smythe. I was just pondering that question myself.”
Dr. Smythe pulls up a chair and Jason shows him the lab work. They both look at the CXR and the latest vital signs on the Emergency flowsheet. Jason then shares his concern about Mr. Thomas still being vascularly dry.
“I agree, Jason. Mr. Thomas is probably still a bit short on fluid. I also agree that we might want to slow down on an 82 year old patient. Don’t want to make the treatment more of a problem than the disease. How about this: before his next lactate, give him another 500 cc NS.”
Jason nods in agreement.
“Then if the lactate is still up and urine output not up to 75 per hour, give him a second 500 cc. I’m going to call the Medicine admitting team and see if they can take Mr. Thomas in the morning, as he is trending better, and at this point he is not really an Emergency patient.”
“Sounds good to me. I will give him another 500 now, and then see what the lactate and urine output is like. Thank you, Dr. Smythe.”
Jim is on the phone with the Medicine floor nurse, who is accepting George Thomas.
“Yes, nothing has happened this morning. I got him up to the bathroom. He is unsteady and does require assistance, but big improvement CNS-wise from admission,” explains Jim. “Yes, yes, yes. The transfer sheet is completed. He has had his antibiotic this morning and the next dose is due tomorrow morning. Family is aware of transfer and doctor’s orders are complete. Ok, thank you. Glen will bring him up to you in less than 60 minutes. Thank you for accepting him.”
Glen, the porter for the Emergency Department, looks up at the mention of his name. “All good for Mr. Thomas to go to med/surg?”
“Appears so. They say they are really busy right now, but I imagine, like everyone, we are all very busy. Let me help you pack him up and take him off the monitor, and then you can take him up to the floor.”
Jim gathers medications, all the paper charting not captured in the EHR and George’s personal belongings. Just before removing him from the monitor, he documents the vital signs and records them on the transfer sheet.
“Ok, Glen, he’s all yours. Mr. Thomas, take care and I hope you feel better soon.”
“Thank you, doctor,” mutters George.
Jim just smiles and helps Glen move the stretcher out of the alcove and into the main hallway.