Day 0

Time: 15h30

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 a shiny Lexus stop in front of the Emergency Room. A middle-aged woman leaps from the driver’s seat and rushes around to open the passenger door. She unfolds a wheelchair and places it on the ground, and an elderly lady slowly eases her way into it.

The woman urgently pushes the wheelchair to the doors, leaving her car where it is parked. Once inside, Jackie notices that the woman displays pursed lip breathing and has a slight blue tinge to her lips. By this time, the duo is at the triage desk.

Day 0 – Miki arrives in the Emergency Room. Image created by Sarah Perkins using a CC-BY-NC license.Jackie comes out from behind the desk. “Hi, my name is Jackie and I’m the triage nurse today. How can I help you?”

“Thank you so much, this is my mother Miki Huang and she started having trouble breathing before we rushed over here. She also has been coughing a bit and it sounds wet, like there may be phlegm?”

Jackie pulls the blood pressure monitor and pulse oximetry machine close to Miki and wraps the cuff around her right arm. She presses a button, and the cuff inflates. On Miki’s left index finger, she places a pulse oximeter.

After about 30 seconds, the machine beeps and displays the following vital signs:

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 Miki’s condition as “Triage Level III – Urgent.”

“Is she going to be okay?” asks Linda, breathlessly.

“I think it would be best if Ms. Huang stays with us for a while and has a doctor take a look at her. I will make arrangements for a spot for her to stay once we get admission paperwork done. Can you and your mom answer a few questions from Denise, the admission clerk who is just to the left of my desk?”

Denise comes over and introduces herself to Miki.

“Good afternoon. My name is Denise.”

Miki stares at her and nods out of politeness, but nothing really registers.

“Her name is Miki and mine is Linda,” Linda interjects. “My mother doesn’t really speak English.”

Denise pauses. “Ok. Linda, 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.”

Linda pushes the wheelchair over to the admissions desk.

“Do you have your Care Card with you?” asks Denise.

Miki continues to just focus on her breathing, but Linda nods ‘yes’ and quickly rummages through her purse for it. She hands it over to Denise, who rapidly inputs the information into the system.

“I see that she was at the clinic last week. Is this correct?”

Linda explains: “They changed her puffers- I mean, her inhalers, and said to come back if there was any problem.”

Denise nods her head. “Make sure you tell the nurses that….do you see anyone regularly at the clinic?”

“No, usually we just see the first doctor available. They change so often, and my mother doesn’t like going, so usually we only visit if it is absolutely necessary.”

Looking up at Linda, Denise asks, “Can I have your contact information, Linda, in case we need to contact you?”

Linda looks bewildered. “But who will tell my mom what the doctors are saying? She doesn’t speak English, remember?”

“We have remote interpreters available for many languages,” Denise explained. “Family members are good support, but they shouldn’t be the main translator.”

Linda looked doubtful, “Well…I would still feel more comfortable staying with my mom though. I’m the one who takes care of her. Would it be fine if I just stayed anyways?”

Denise hesitated, “Sure, that’s fine. It may take a while though, just warning you. I have called for a porter, and they will move to a spot where the doctor can see you.”

Denise watches as the porter comes up to both Linda and Miki and begins pushing the wheelchair through the doors into the back area of the Emergency Ward.

The mother and daughter pair are abruptly left in the hallway. Linda reaches around to grasp her mother’s hand, who grips it tightly. She looks around the chaos and sees people moving from curtained area to curtained area, all dressed in identical blue scrubs. No one makes eye contact or even acknowledges them as new arrivals.

She didn’t want her mother to know, but Linda secretly worried about the whole situation. “If only we were back in Taiwan,” she secretly fretted. “What if I say something wrong or don’t understand something? What if I don’t know the right words?”

Just then, she feels a presence behind her. Turning around, she sees another nurse dressed in light blue holding a clipboard.

“Are you Ms. Huang and her daughter?”

Linda nods for the both of them while Miki remains passive.

“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?”

“Yes,” Linda blurts out. “My mother only speaks Taiwanese and Japanese, so I will answer for her.”

“Ok then. Linda, why don’t you sit by the side over here,” Jason says, gesturing as he pulls up a chair closer to Miki.

“When did you begin to feel short of breath?” He watches the younger relay the question to the older.

“She said before we got her new inhalers she would sometime feel out of breath, but today she suddenly couldn’t breathe again. She felt pretty weak all day,” Linda states.

Jason writes the information directly onto the second page of the nursing record.

“The clinic notes indicate you have COPD. Is that correct?”

“Yes, she does.”

“And do you have any other conditions?”

“No,” Linda says. “She’s overall pretty healthy.”

“Okay, that’s all the questions for 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 closer to the wheelchair, but as he starts to attach the blood pressure (BP) cuff and the pulse oximeter, Miki seems to startle.

Jason notices this and hesitates, but Linda is quick to reassure her in their native language that the doctor is simply checking her vitals.

He presses the button and as the cuff inflates, Jason observes Miki carefully. He notes that her airway is patent, and her breathing is rapid at 28 breaths/minutes and appears shallow, with some nasal flaring. Periodically, she coughs with great effort, and it sounds like there is phlegm in her system.

The blood pressure cuff dings and the results appear on the screen.

“Ok, Ms. Huang. Your blood pressure is higher than I would expect. Is this normal for you?”

Linda leans forward. “I think so? I remember it being in the higher range, but it’s also been a while since she last got her blood pressure taken.”

Worried, Miki pulls on Linda’s sleeve, wondering where the conversation is going. She cannot understand anything that is happening at the moment and worries that something is wrong with her.

“Don’t worry Mom. I was just telling the doctor I think your blood pressure has always been a bit higher” Linda explains.

Relieved, Miki eases back into her wheelchair. “Hopefully I’ll be home by tonight,” she thinks to herself. “The new episode of that singing show is coming out soon.”

Jason continues. “Your oxygen saturation is also a bit low, so I’m going to put you on a little oxygen. Is that okay with you?”

“Of course!” Linda exclaims.

“Sorry, if I could get an affirmative from Miki herself that would be great,” Jason says.

“Oh, sorry, of course,” Linda says. She turns to her mother and explains, and Jason sees Miki nod, although it comes with some frowning and hesitancy.

“My mother’s wondering how long she has to stay here for?”

Jason pauses. “The doctor will be able to give you a better answer. Why don’t we wait and see what they say?” He 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, then sets the flow at 2 Litres Per Minute (LPM).”

“Let’s see if that helps with your shortness of breath. I’m not 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 okay with me examining you?”

Linda starts translating to Miki, whose brows furrow deeper and deeper. Jason notices that even with her shortness of breath she can convey great objection and dissatisfaction. Linda and Miki both seem to forget that he is there, and the conversation starts to escalate, with Linda seemingly trying to persuade her mother. They both sigh before Linda turns to face Jason again.

“She’s not happy in this hallway and scared that she’ll be accidentally exposed.”

“I totally understand, but we’re super busy right now and I have no other place to offer you at the moment. Hopefully this will only be for a couple of hours. So do I have permission to examine her?”

“Yes, she agreed, but she also warned you to be careful,” Linda says tiredly.

Jason nods and carefully slips his stethoscope between Miki’s clothes and skin. Closing his eyes, he moves the stethoscope systematically first to the anterior chest, then to the posterior chest. After listening, he quickly examines her abdomen and extremities.

“Ok, Miki. I just finished. I see your oxygen levels appear to be a bit higher. Are you feeling a little less short of breath?”

Linda quickly starts speaking, and Miki begins to nod.

“Yes, she said she feels 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.”

Linda nods and shifts her feet around. Miki peers around with trepidation and shivers slightly. Linda immediately notices and wonders if she should tell Jason that her mother is cold, but watches as he moves toward 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 can’t believe my mother has to sit here in this hallway to wait. Can’t they see how old she is? Is this what we pay taxes for? I wonder if they treat all their patients like this. I can’t wait to get out of here; I still have work tomorrow.”

Jason looks at the various people huddled around the nursing station.

Jason 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. “Okay, 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?”

Jason summarizes his findings with Miki’s report and explains, “I just came on shift as well. New patient, Ms. Huang, 96 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, otherwise known as oxygen saturation. 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.”

“Okay, 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 yet. With her diagnosis and potentially frequent antibiotic use, it could set her up for a superbug. How does that sound?”

“I agree, and thank you. I’ll get the RT for the arterial blood gases (ABG) and see if medical radiography can do the X-ray portably.”

Dr. Singh pulls out a doctor’s order sheet. Jason places a sticker with Miki Huang’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 it when my day starts like that. I once had to bring little Kim to work when my daycare was late as well. Cathy picked him up half an 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 onto a computer located just a few feet from Miki.

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 Miki and notes that she is sleeping in the chair.

“Wow, I wonder when she last had a good sleep.” Jason decides not to disturb her and instead gently touches Linda’s arm to update 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.

Linda nods, looking exhausted and frantic.

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 prepares you for the job, but nothing can prepare you for the endless 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 most of the shift.

The lab supervisor approaches her. “Emergency is super 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 requisitions waiting.”

“Okay, 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 Department 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, pushes the button. As soon as the doors open, she instinctively leans back from the noise and smells and overwhelming sense of chaos.

“Oh wow…school definitely did not prepare me for this…”

Navigating her cart through the Emergency Department, she thinks to herself, “It’s just like driving during 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 requisitions are waiting. She notes that James has taken all the urgent request (STAT) ones, as there is not a single one in the pile. Looking through requisitions, she observes that they are all pretty similar and all the requisitions have close to the same time on them.

“Okay, let’s start with this one,” she says as she places Miki Huang’s requisition on the top of her board. Looking at the req, she pulls out the appropriate lab tubes and labels them with Miki Huang’s 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 after a while I guess.”

“I’m looking for a Miki Huang?”

“Miki is my patient. Let’s walk over here and down this corridor. I’ll introduce you to both her and her daughter Linda. Unfortunately, the patient can’t speak English, which is why Linda is still here. She seems really worried…. say, I haven’t seen you before, are you new?”

“Yep, 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 all knowledgeable and quite caring.”

As they move down the hallway, Alexa sees an elderly lady, still in her normal clothes with a light blanket wrapped around her shoulders, sleeping in a wheelchair. Beside her, a middle-aged woman fidgeted and shuffled her feet, eyes darting up and down the hallway. Alexa could feel that she was protective of the older woman.

“Is that…?”

“Yes, that is Miki Huang.”

Jason moves confidently up to the pair and briefly speaks to Linda, before lightly touching Miki’s arm. Alexa notes that Miki’s eyes snap open quickly and appear sharp, not withdrawn, like some of the patients she has seen.

“Ms. Huang, this is Alexa, one of our lab technicians. She’s here to take some blood from you. Is that okay?”

Linda speaks rapidly in a language Alexa can’t place, and then Miki nods slowly.

Alexa moves her cart closer. Looking at the requisition and then at Ms. Huang , she says, “Can you tell me your name?”

Linda answers, “Miki Huang.”

“Birthday?”

“September fifth, nineteen twenty-six.”

“Excellent, thank you.” Alexa checks the identification band on Miki’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 (WHO) guidelines, Alexa prepares to take the blood specimens.

Alexa first asks Linda to help Miki roll her sleeve up a bit more, but this seems to irritate Miki, who insists that she can do it herself. Carefully putting the tourniquet around Miki’s right upper arm, Alexa then swabs her inner ante-cubital 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 anticoagulant. After that, she carefully places the tubes in the holder in the front of her cart.

“I’m all done, Ms. Huang. I hope you feel better soon.” She smiles reassuringly to convey what words cannot.

Alexa moves away and heads towards the nursing station. She looks down at the next requisition 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 several emergency patients and floor patients. No requisitions are marked as stat.

“Okay, 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 Ms. Miki Huang 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 stations at the far end of the hallway, he looks at Sheila, the unit clerk. “Hiya, 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.

“I’m here to escort Ms. Miki Huang to the Radiology Department for a picture.”

Sheila looks at her assignment list and finds that Jason is the nurse. “Okay, Jason is caring for her. And there he is, talking to the patient’s daughter.”

“Huh, wonder why she stuck around. Thanks, though. 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 the trio huddled in the hallway.

“Hi, my name is Glen and I’ve been asked to escort Ms. Huang here to 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 explains to Linda that Miki needs a chest X-ray to help them figure out why she is short of breath. Miki, impatient, leans forward in her seat, yearning to understand. Was she going to be okay? What was going on?

Linda looked down at her frail mother. “Don’t worry Mom, they just need a few X-rays, okay?”

“Alright, I guess. At least I’ll be out of this noisy hallway,” Miki sighed.

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 Miki the weather outside, the hockey game, and recent city events. Miki sits in her chair and wonders why the man won’t stop talking. And although she would never show it, she is secretly relieved to hear the pattering of her daughter’s feet hurrying after them.

Glen and Miki roll through the doors of the Radiology Department after taking the X-ray to see Gurpreet standing at the desk.

“Here is Ms. Miki Huang, from Hallway B in the Emergency Department.”

“Thank you, Glen. Can you place her in Room 2, please? I’ll be right behind you.”

Time: 19h30

Place: Emergency Room, Hallway B

Having come back from radiology, Miki and Linda once again find themselves in the hallway.

“Linda, can you ask when we’ll get the results?” Miki whispers impatiently.

Reluctant and afraid to be a bother, Linda asks Glen, who looks down at Miki. “Tell her I’m not the one to ask. I can let Sheila know that you’re back, so the doctor and Jason can look at your X-ray images.”

Linda thanks Glen profusely as he walks away to the nursing station to inform Sheila that the chest X-ray is completed.

Miki 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. “I can’t believe they know how old I am and haven’t even offered me a bed yet. My backside is getting sore. This would never be happening back home.”

Without realizing it, Miki’s eyes slowly shut. Suddenly, she feels a touch on her hand. Startled, she gives a little shout.

“Oh oh oh, it’s okay. My name is Matt. I had no intention of scaring you. Wow, I’m really sorry Ms. Huang.”

Miki turns to look at Linda, wondering why she didn’t interject.

“He said he’s sorry, Mom.” Turning to Matt, she continued, “Don’t worry about it, my mother’s had a tiring day. We’re all pretty tired, actually.”

“Completely understandable. Well, 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 looking at the results in your chart. And the second one is a blood gas.”

The word “test” vaguely registers in Miki’s head, and her brows furrow with concern.

Matt looks between mother and daughter. “Shall we do the spirometry first?”

He opens a small plastic bag to retrieve a freshly sterilized kit tube with a gauge on it. He quickly describes what he wants Miki to do. “Ms. Huang, 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.”

At this point, Linda is extremely worried about saying the wrong thing or giving the wrong directions and messing up the test. She translates with some hesitancy in her voice, and Matt, picking up on this, also feels a tinge of worry that he tries to brush off.

Miki, however, sits up a but straighter in her wheelchair and nods, ready to do her best.

Matt hands Miki the device. “Please tell your mom to take a deep breath, then blow through the tube.”

Miki does as instructed, three times. After each time, Jason records the results on the requisition for spirometry.

“Okay, we’re done for now. You did a great job, Miki.”

Miki, understanding that they are finished, pats Matt’s hand gratefully.

“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.”

“Wait, aren’t those painful?” Linda interrupted. “I think she’s done one before, and I remember her complaining endlessly.”

“I’ll try my best not to hurt her, but it is uncomfortable. Which hand does she use the most?”

“She is right-handed.”

Matt gently takes Miki’s left hand and bends her elbow 90 degrees. He then performs the Allen test, which is a standard test used to assess the arterial blood supply of the hand, prior to doing arterial blood gases.

“Okay, everything looks good, Ms. Huang.”

Matt then rubs an alcohol swab vigorously across Ms. Huang’s wrist. Then, he waves his hand back and forth to disperse the smell.

“I need her to relax and stay still while I do this, okay?”

Linda relays the message to Miki, who sighs with displeasure. This day could not get any worse.

Matt, holding the syringe at a 45-degree angle, slips the needle under Miki’s skin. Quickly, the syringe fills with red fluid. Matt then withdraws the syringe and holds a gauze over the site.

“That was pretty good! You’re doing great, Miki.”

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 Linda to tell Miki 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 Miki, and gestures for her to take away the gauze.

Matt sees 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 Miki’s wrist.

“Please leave this dressing on. We can take it off later tonight, but I want to make sure you don’t end up with a big bruise.”

Matt steps away to find Jason and show him the results from spirometry and the blood gas. He finds Jason at the computer in the nursing station.

“Hi Jason. I have the results from spirometry and blood gases for Ms. Huang.”

Jason looks up, smiles and says, “Okay, anything special?”

“Spirometry shows a decrease in vital capacity from what was taken at the clinic a couple of months ago. That’s not surprising, given that she’s back here. The ABG shows a rise in CO2 and just normal partial pressure of oxygen (PaO2) on 2 LPM oxygen. She’s 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.”

“Hmm. Are the results on the clipboard?”

“Yes, and I hope you don’t mind I wrote the ABG in the chart as well.”

“You’re awesome. I’ll go find Dr. Singh when I’m done here and see what he would like to do, but my guess is she’s going to have to stay the night.”

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

“I’ll go talk to her.”

“Actually, you’ll have to go talk to the daughter. I didn’t mention before, but the patient actually doesn’t speak English at all.”

Dr. Singh stares at Jason. “Okay, then…”