Case Study #6: Sepsis
Place: Sleepy Hollow Care Facility
“Janey, come and help me. I can’t wake George.”
Janey, the charge nurse for the day at Sleepy Hollow Care Facility, looks up from the computer and sighs. “Gosh, this has been a challenging day. Two clients missing this morning, a family upset that it’s not an all-inclusive resort, and now George.”
Janey gets up from the desk and quickly recalls information about George in her mind. He is a character, likes wearing his train hat all the time, does yoga, but I think that’s just to meet women, and can recite seminal movie lines from every movie ever made. The smile disappears from her face. “Why is he not waking up?”
Walking quickly down the hall, she enters George’s not-so-tidy suite. “Hi, Preet. Why is George not responding?”
“I just can’t wake him. I have shaken him and shouted his name, but he doesn’t respond. And before you ask, yes, he is breathing and has a pulse.”
“Thank goodness. Well, let’s get him on some oxygen, call the ambulance, and see about moving him to the hospital.”
Janey moves out of the room to use the hallway phone and dials 911.
“911. What is your emergency?”
“I’m the charge nurse at Sleepy Hollow Care Facility. We have a client that is unresponsive and requires an ambulance.”
“Thank you. Transferring you to Ambulance Service.”
“911 Ambulance. How can I help?”
“I am at Sleepy Hollow Care Facility. We have a client that is unresponsive.”
“Does the client have a pulse?”
“Yes, and he is breathing.”
“Do you have a blood pressure?”
“We are getting his pressure now.”
“How long has the client been unresponsive?”
“Not sure.” Janey calls out: “Preet, how long has he been unresponsive?”
“About 90 minutes ago he was fine.”
“Did you hear that?” Janey asks the 911 operator.
“Yes, client unresponsive with pulse and breathing. Has been like this for up to 90 minutes. Anything else I need to know? An ambulance has been dispatched.”
“No, we’ll talk with the paramedics when they arrive.”
“Do you want me to stay on the line?”
“No, as long as ambulance has been dispatched I think we’re ok. How long for paramedics?” Janie inquires.
“Should be there in about seven minutes. I’ll hang up now, but if condition changes, call 911 again.”
Place: Ambulance Station
“Ambulance 52,” the dispatcher’s voice broadcast through the ambulance station. “Unresponsive patient, Sleepy Hollow Care Facility. Client has respiration and pulse. Proceed code 2.”
“Roger that, Dispatch. 52 heading to Sleepy Hollow Care Facility, code 2.” James looks up from completing the call log and touches the button for the emergency lights. “Ok, you heard the lady. Let’s be off.”
James’s partner, Zac, smiles. “Not sure Dispatch likes being called that: lady.”
Zac quickly moves the large ambulance out into traffic and navigates through the congestion while lights and car drivers freeze at the very sight of an ambulance.
Place: Sleepy Hollow Care Facility
“Great time in getting here, Zac.” James writes the arrival time at the top of the ambulance form.
Both paramedics hop out of the ambulance and open the rear doors. Pulling the stretcher out and setting its wheels on the ground, James looks at Zac. “Ok, what should we take?”
“Unresponsive patient: need the airway box, defibrillator, and drug/IV fluids box.”
“I agree. Let’s grab that stuff.”
Zac hops in and quickly locates the three boxes and places them on the stretcher.
Once through the doors of the care facility, the two paramedics stop at the front desk and identify themselves.
“Yes. Janey is expecting you. Go out through the doors behind you, turn left, then turn right at the end of the hall. George’s room is on the left. There will be an orange cone out in front.”
Both paramedics walk quickly down the hall and turn right to find a tall, well-dressed woman standing outside a room marked with an orange cone.
“Great, you’re here. Come on in. This is George Thomas’s suite.”
The paramedics leave the stretcher just outside the room and follow Janey into the room to find another woman in a nursing uniform holding George’s hand.
James looks about quickly and thinks, Slightly messy room, patient is in his own clothes, chest rising, colour is not great, a bit ashen. Looks sick.
To Zac, he says, “Ok, Zac, go check George out. I will get more information from…?”
“My name is Janey. I’m the charge nurse for today.”
“Thanks, Janey. What can you tell me about George?”
Janey reaches over and grabs the Kardex from the top of George’s dresser. “This is usually on the back of the door. Anyway, George Thomas is an 82 year old, reasonably healthy client, active, widowed, which is why he came to live here, and he has a daughter who is a bit of a challenge. Last week he was diagnosed with a UTI and was placed on antibiotics. Usually we let patients deal with their own meds, but George kept forgetting, so we have been giving him his antibiotics regularly. In the last 24 hours he seemed to be occasionally confused, and this morning needed guidance to breakfast. After lunch, we didn’t see him until Preet went to check on him and reminded him it was close to dinner time, and found him unresponsive.”
James quickly writes the information into the ambulance record. “Anything else regarding health issues?”
“He has type 2 diabetes and has been investigated for a heart murmur, but nothing further on that. He has been a healthy, active client while he’s been here. No trouble at all, except he likes the ladies.”
James smiles. “Thank you, Janey. Zac and I will check George out and see what we can do for him.”
“Thank you. I’ll go let his daughter know. Oh, one last thing, he is a DNR level 3.”
“That helps a lot. If we can, we will try not to transport to hospital, but I am thinking we’re going to be taking him to Memorial.”
“Ok. I will leave Preet here to help.”
James turns to his partner. “How are you doing?”
“Good. RR 28, shallow excursion, breath sounds slightly coarse at bases, HR is 110, sats in the low 90s, BP 98/60. His colour is a bit ashen and he feels cool to touch. I think he might be septic, but not sure of the source.”
|Day: 0||Pulse Rate||Blood Pressure||Respiratory Rate||Temperature||O2 Saturation|
|Time: 18h00||110||98/60||28||cool to touch||–|
“I agree that he might be septic, as well. He’s being treated for a UTI, so that could easily be his source. Given that his BP is a bit lower, let’s start an IV and give him some NS. Place on monitor and ready for transport.”
“Sounds good. You want to do the IV or me?”
“Uh, Zac, you start the IV with Preet’s help. I’ll get the monitor and call ahead to Memorial.”
The two paramedics and Preet complete their tasks and transfer George to the ambulance stretcher.
Janey reappears with a large envelope. “These are his medical records that we have to date. I have photocopied them for you, as I know they will ask. Anything else? Do you need a nurse to go with you?”
“Thanks for the chart. No, we’re good, just Zac and I. Memorial is aware and is trying to find a space for George now.”
- Please check the resuscitation codes and levels of care relevant to your clinical context. ↵