Appendices: Case study for Pneumonia

Day 1 Emergency Department & Medical Unit

Annabelle Liao

Day 1

Time: 02h00

Place: Emergency Room

Jason decides to take another set of vital signs:

Day: 1 Pulse Rate Blood Pressure Respiratory Rate Temperature O2 Saturation
Time: 02h00 86 160/90 22 36.5°C 90%

Time: 02h30 

“Dr. Singh, here are the spirometry and ABG results on Miki Huang.”


“Thanks.” Dr. Singh reviews the results and comes to the same conclusions as Matt and Jason. “Let’s look at her chest X-ray.”


Dr. Singh pulls up the X-ray film onto the computer and both lean in to view the black and white image. Jason looks at the image and then at Dr. Singh, thinking to himself that it looks like a normal X-ray except that the lungs look a bit long.


Dr. Singh sighs, “Okay, the X-ray shows a small number of infiltrates at the bases and typical COPD hyperinflation. Nothing that I would consider abnormal in itself, but when we consider the ABG and the spirometry all together, I would like to keep her overnight to see if she is going to get better or worse. If it’s pneumonia, she will get worse overnight and the next day. If it’s just the cool weather we are having and nothing infective, she should get a bit better with some care and attention. What do you think?”


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


“I’ll go talk to her.”


“Hello, Ms. Huang, My name is Dr. Amir Singh. I am one of the many people here taking care of you.”


Ms. Huang stares back, brows furrowed.


Dr. Singh smiles reassuringly and continues, “Both Jason and I have reviewed your tests and we believe you should stay overnight with us. I don’t think it’s serious, and if you are able to get a reasonable sleep, and a few more puffs of the meds I have ordered along with some oxygen, you may feel better in the morning.”


Still Ms. Huang remains silent. Just then, Jason comes running up from behind.


“Sorry Dr. Singh, our patient doesn’t speak English, remember? Her daughter Linda has been translating this entire time, but it seems that she went home briefly to get some matters sorted.”

Miki is alone in her wheelchair in the ER hallway. She is surrounded by male staff who are talking to each other an not her.
Day 1 in ER – Miki is visited by hospital staff while Linda is absent. Image created by Sarah Pinault using a CC-BY-NC license.

Dr. Singh nods, “Yes, I can’t believe that slipped my mind. Perhaps we had better get Linda on the line and update her.”


Throughout this entire exchange, Miki sits in her wheelchair and coughs occasionally, growing increasingly impatient. Jason bends down to meet her eye level.


“Hi Ms. Huang,” he slowly enunciates with big gestures, “I am going to call Linda and tell her you need to stay overnight. Give me a few minutes.”


Miki glares back and wonders if he realizes that even if he speaks slower, she still cannot understand English.


Time: 02h35

Place: Home

Linda collapses on the couch, thoroughly exhausted. She tells herself that she’s just resting for a quick minute and no more. So much has happened and her head is still spinning. It briefly crosses her mind that she still needs to work tomorrow. Her eyes flicker to the blaring television, which wasn’t turned off in their rush to the hospital. Although she’s trying her best, Linda cannot stop thinking about her poor mother alone in the hospital and imagining every worst possible outcome.

Linda is tired and resting in a reclining chair
Day 1 in ER – Linda is home, resting briefly. Image created by Sarah Pinault using a CC-BY-NC license

Just then, her phone rings and she lunges for it. It is the hospital.


“Hello?” she answers breathlessly.


“Hi Linda, this is Jason from the hospital. I’m just calling to inform you that myself and Dr. Singh have reviewed Miki’s tests and think that it’s best if she stays overnight with us. It shouldn’t be too serious; we would just like to observe her symptoms for a bit longer to see if she gets worse.”


Linda’s head starts racing. “But is that really necessary? Who is going to help my mother? How is she going to ask for help or answer your questions?”


Jason tries to reassure her, “Not to worry at all, Linda. We have interpreters available in many languages and I can arrange one for your mother. The interpreters are all highly qualified and certified medical interpreters and I’m confident they can help.”


“But how long are they going to take to get there? And how do you know they’ll understand? My mother is so old. I should be there for her,” Linda protests.


“Linda, you need to take care of yourself too. I will make sure your mother receives the best care possible. We’re arranging a bed for her right now. I’ll also call the interpreting services right after.”


Linda hesitates briefly, then makes up her mind. “I’m calling in sick to work and then I’ll be right there to be with my mother. There’s no need to call interpreting services,” she states resolutely.


After hanging up, she immediately lets her work know she won’t be available for the next few days, splashes cold water on her face, and is promptly in her car on the way to the hospital again.

Time: 03h00 

Place: Emergency Room

Reunited with her mother, both mother and daughter feel more at ease again. Jason has already updated Linda on her mother’s situation, and now Dr. Singh is speaking to her.


“Hello, Linda. I just want to preface this conversation by reminding you that we have excellent interpreters available. It’s actually recommended that these interpreters be used instead of family members, because they’re very well versed in medical terminology.”


“No, thank you. They may know more medical terms, but they don’t know my mother like I do.”


Dr. Singh nods. “Alright, but make sure you take care of yourself. It’s not going to be super comfortable for you given the spaces available at the moment. You can only take care of your mother if your own wellbeing is maintained too.”


“Thank you Dr. Singh; I’m sure I will be fine.”


Just then, a nurse gestures to Dr. Singh from Bed 3.


Jason tells the pair, “Give me a couple of minutes and I will find you two a more private location.”


Linda nods gratefully, and quickly relays this message to Miki, whose mouth turns upwards ever so slightly.


After a discussion with the charge nurse and getting housekeeping to clean an area from a recent discharge, Jason is able to move Miki into the last stretcher bed farthest from the nursing station and the doors. It’s the most private location they have and a coveted location for staff to take their breaks.


“This should be a lot better for Miki. You need to let me know if she needs to use the washroom as I will get another oxygen tank on wheels for her to use when she’s up.”


“Thank you so much again. And is there room for me here too, or where should I go?”


Jason hesitates, “Well, we wouldn’t be able to arrange a bed for you…”


“That’s okay. I’ll be right next to my mom. I’m pretty sure I have a little stool in my car somewhere.”


“Okay, Linda. I’m just going to take one more set of vitals and then your mother can sleep. If she needs anything, please push the call button.”

Day: 1 Pulse Rate Blood Pressure Respiratory Rate Temperature O2 Saturation
Time: 02h00 86 160/90 22 36.5°C 90%

Time: 07h00

Place: Emergency Room

Dr. Notley is reviewing the list of patients to see this morning when he is approached by the charge nurse with a list of overnight patients that potentially could be sent home if everything is well.


“Can you look at these patients first? Let me know which ones can be sent home. Ms. Miki Huang in the far room appears to be a little worse. We may need to find her a bed.”


Dr. Notley nods. “I’ll see her quickly and then take a look at the potential discharges. I trust your judgement so start drawing up the paperwork on those patients so that when I agree we can move them quickly.”


Dr. Notley pulls up Miki Huang’s electronic record: Exacerbation of Chronic Obstructive Pulmonary Disease (COPD), on 2 LPM nasal prongs, ABG shows higher than normal CO2 and drop in PaO2 with maybe something on the Chest X-ray (CXR).


Dr. Notley walks quickly down the hall to the last stretcher in the row of 20. Seeing the curtain partially open, he announces himself, “Good morning, I’m Dr. Notley. You must be the nurse taking care of Miki?”


“Yes, my name is Jackie; it’s very nice to meet you. “


Jackie waves him in. Dr. Notley also notices a middle-aged woman on a little stool in the corner just as Jackie speaks up.


“Right now, Ms. Huang is not doing as well as expected. I was at the triage desk yesterday when she came in. This morning, I have increased her O2 to 5 LPM and I’m asking the RT to come by and assess her for face mask or Optiflow. I am not sure which option is best.


Her sats have stayed at 90-91% on 5 LPM, work on breathing appears increased, and her breath sounds have expiratory wheezes in upper fields with coarse crackles in lower fields.”


“That is a bit disappointing. How are you feeling, Ms. Huang?”


Miki, gauging the newcomer, notices his neat hair, unwrinkled lab coat, and stethoscope. “Now this looks like a proper doctor,” she thinks approvingly.


Linda, now alert, answers for her mother: “Hi Dr. Notley, I’m Linda her daughter. My mother can’t speak English so I will be translating for her.”


She quickly confers with Miki, then looks back up at Dr. Notley. “She said she’s tired and can’t catch her breath. She also couldn’t get out of bed herself. What’s happening to her?”


“Well, Linda, that is a very good question. We anticipated that your mother would get better with additional inhalers and a good night’s sleep, but obviously that has not happened. I am going to listen to her chest and then order some tests to help find out why she’s not feeling like herself. I expect that we’re going to have to start her on some antibiotics and admit her to the medical floor for additional treatment.”


Linda’s looks simultaneously frantic and exhausted. “But my mother doesn’t want to stay here. And I’m already behind on work too. I need to be here for her.”


“Linda, I would like your mother to stay. Whether you stay is completely optional and up to you. I know that it’s challenging being away from family…”


“How can you tell me staying is optional? Am I supposed to just let my mother fend for herself here? At least I could take care of her while working if we both went home.”


“Your mother has a long-term condition called COPD (Chronic Obstructive Pulmonary Disease). I suspect that she also has pneumonia as well. If you both go home, she will likely get worse.”


“You mean die?!”


“Yes, that could happen. I don’t ask my patients to stay without a good reason. Do you trust me?”


Linda looks down and rubs her hands together. “Yes, of course. You’re the expert here. But I will be staying here with my mother until she gets better.”


Miki, who has been observing from the bed during the entire exchange, grows increasingly frustrated. Nobody was telling her anything even though it was her body that there was something wrong with. She’s not used to feeling powerless or not being in charge, and she absolutely hates it. She clears her throat as loudly as she can. “Linda, tell me what they’re saying,” she demands.


Linda relays the doctor’s words to her mother as quickly as she can, and Dr. Notley watches the older woman’s face become visibly upset. The pair seem to be arguing, although he cannot really tell.


“Mom, I’m telling you, it’s the doctors who are saying you have to stay.”


“Nonsense. I know my body best. They won’t even know how to treat me here; I have my own treatments at home. There’s one that can clear my airways, you know.”


Linda can barely contain her frustration. “Mom! You have something called COPD; the doctor said it’s very serious. You could die!”


“Don’t even say that!” Miki answers sharply. “I know my body best, not these people I met 5 minutes ago. Besides, my own stuff at home is just as good as this Western medicine, and more natural too.”


Linda seethes, “Well, guess what? I’m not driving either of us home until the doctors clear you, so too bad.”


Miki is shocked. What is happening? Her daughter never spoke to her like this. Linda interprets her mother’s silence as compliance and stares her down.


Finally, Linda looks back to Dr. Notley. “Okay,” she says wearily, “We’ll both stay, although my mother’s pretty torn up about the situation. She said you better heal her fast.”


Dr. Notley smiles. “Thank you. I am going to listen to her chest and then write some orders for tests and talk with the medical team to get her a bed as soon as possible. Her stay with us may not be as long if we can get the right treatment.” Dr. Notley lifts his stethoscope off his neck, places the earpieces in his ears and gently places the bell on Miki’s chest. He listens methodically, anteriorly and posteriorly.


“Thank you, Ms. Huang. Jackie and I are just going to step out now and see a couple of other patients, but we will be back.”


Jackie and Dr. Notley step through the curtain and make their way to an alcove to have a more private discussion.


“What do you think, Dr. Notley?”


“I agree with you Jackie, Ms. Huang looks a lot worse. Her chest sounds very congested and wheezy. O2 requirements are going up. I expect she has community acquired pneumonia. I would like to order another CXR, CBC, ABG, and a sputum sample. I’ll see if the lab has the gram stain on the earlier sputum sample which may help guide us. I will also order some antibiotics but will check with the pharmacy to make sure I order the correct one. I will admit her and let the medical admit team know they have a new patient. Anything else you need?”


“That sounds good. I will have the RT get the ABG now so we can get the right O2 therapy.” “Excellent. Your other two patients are on my discharge list. How are they doing?”


“Both are fantastic. No complaints and both are already dressed and have called for a ride. They both need prescriptions for the meds that were ordered last night. Once you have seen them, I will move them to the waiting room so we can get the areas clean and ready for a couple of the hallway patients that need a spot.”


“Okay. Let me quickly see them. I’ll write the scripts and discharge orders so you can move them. Thank you.”


Jackie hesitates, “Actually, I would probably also recommend bringing a translator in for Miki…I can see how dedicated Linda is to taking care of her mother, but I’m thinking with both her and her mother’s best interests in mind right now. From what I’ve seen, having a family member act as translator could get a bit messy. It’s also just not as efficient in my opinion, but obviously I’ve never had personal experience with this. However, I do know that there is on-demand phone interpreting here at the Vancouver hospitals, or a professional translator can be dispatched to us within a few hours…and I think some places even offer remote video interpreting now.”


Dr. Notley thinks, “Yes, I can see what you’re saying. It’s also commonly taught that the role of family is to support only for fear of becoming too involved or making decisions on behalf of the patient. Well, we can’t force Linda to leave, but I can bring it up again. I know that we can have professional interpreters here immediately with on-demand phone interpreting, or book one to be here in a couple of hours. Let me double check to make sure this information is accurate, and I will speak to the two again.”


Dr. Notley heads over to Beds 18 and 19 to talk to the patients ready for discharge. Jackie waits for a bit in case he needs something, and then moves off to the nursing station to page the RT.

Time: 07h30

Jackie sees Alexa, the respiratory therapist, come into the unit and quickly walks over to her.


“Hi Alexa, do you have a minute to check a patient with me and draw an ABG?”


“Oh, hi Jackie, just give me a minute to finish running this blood gas and gather some stuff. I can meet you at the bedside. Which patient?”


“It’s Ms. Huang in the back room.”


Alexa nods and rapidly walks over to the ABG machine to run the blood gas. Jackie turns and goes to Ms. Huang’s stretcher.


“Ms. Huang, Alexa, a respiratory therapist, will be here shortly to assess you and draw a blood gas which will help us help you.”


Linda quickly interjects, “Oh, she had one yesterday too I think.”


“Yes, that’s correct. And here is Alexa.”


Alexa places her hand lightly on Miki’s wrist to feel for a pulse and introduces herself. “Hi Ms. Huang, I am Alexa, a respiratory therapist. I am going to listen to your chest, poke your wrist here for a blood test, and depending on the result, make some adjustments to your oxygen therapy before you head upstairs to the ward. Are you okay with that plan?


Miki’s head spins, exhausted of being overwhelmed with words and syllables that were so familiar yet so incomprehensible still. She shuts her eyes and wishes she could just go home and sleep, and a deeper part of her is worried about her daughter’s job and guilty about being such a burden.


“Yes, she’s fine with that” Linda interjects.


“Okay. She appears quite short of breath, so I won’t ask her to move around a whole lot.”


Although Miki doesn’t understand the uttered words, she comprehends that Linda agreed to something based on her tone of voice. She feels a twinge of annoyance at her daughter consenting to something on her behalf without consulting her first, even if it was something small. Ever since arriving at the hospital, she has felt nothing but powerlessness and vulnerability. Besides physically being too weak to plan and carry out any of her usual activities and having to submit to the orders of all those doctors, she completely had to rely on Linda because of the language barrier. This instance literally proves her absolute dependency, and she is hating every minute of it.


Alexa checks the oxygen flow, the position of the nasal prongs, and listens to Miki’s chest. Taking her right wrist, Alexa performs the Allen test.


“Everything looks good. I am going to go ahead and do the test now.”


Alexa efficiently obtains the ABG. Miki does not even flinch and is just lying back in her bed breathing rapidly.


“You did great, Ms. Huang. I am going to have Jackie hold your wrist for a few more minutes while I go and run this sample through a special machine.”


Jackie comes over and holds Miki’s wrist firmly to prevent bruising. Alexa moves off quickly to the blood gas machine. Her services temporarily not needed, Linda allows herself a few moments to space out and think about nothing.


A few minutes later Alexa comes back. She takes a look at Miki’s wrist and puts a light pressure dressing on it. She then shows Jackie the ABG results.


Day: 1 pH O2 CO2 HCO3 SaO2
Time: 08h30 7.3 65 52 27 89


“Thanks Alexa, the blood CO2 level is about normal for Ms. Huang with the COPD but the oxygen levels are much lower which is a bit concerning.”


“I agree, I think I will place her on Optiflow right now, and when she goes up to the floor ask whoever is covering up there to take another look. I think we can follow just with monitoring her on the pulse oximeter and not require another blood gas until maybe tomorrow.”


“Sounds good to me.”


Jackie leans down and explains the plan to Linda, who wearily tells Miki, who weakly nods her head.


Alexa moves off quickly to gather the Optiflow equipment and returns a couple minutes later. She sets up the humidifier and places the high flow nasal prongs in Miki’s nose. Making some adjustments to the flow, Alexa leans in. “How does that feel, Ms. Huang?”


Miki looks at Linda, who is staring off into space. Feeling eyes upon her, Linda startles. “Oh! She’s asking you how that feels, Mom.”


Miki tells her daughter that she feels fine as Alexa leans in. Looking up at the oxygen saturation (SaO2) displayed on the screen, both Jackie and Alexa can see the number increase to 93%.


Alexa listens to Miki’s breath sounds and finds no real changes.


“Okay Jackie, I think she is fine right now. Dr. Notley ordered a CXR, and I think we should do it portably. I will call the department to ask them to do so. I think the transport to X-ray and back may be too much activity at this time.”


“I agree. I can call them if you want?”


“Not, I’ve got this. You probably have other things to do this morning.” Alexa indicates the two patients that need to be moved to the waiting room and have their discharge forms completed.


“Yeah…it’s been pretty busy but not too bad. Almost feels slow given how it was the last couple of days.”


Alexa smiles and moves towards the nursing station to call the X-ray department. Jackie walks over to the two patients waiting in chairs for their paperwork to be completed so they can leave.


Alexa calls X-Ray Department  

“Hi, this is Alexa. I am the respiratory therapist in the Emergency department. I think you have a requisition for a CXR for Ms. Miki Huang?”


“Just a minute, let me check.”


Alexa hums a Drake tune to herself as she waits. Smiling, she remembers his concert from last week.


“Yes, we have the requisition for Ms. Huang. I was about to call for a porter for her as we are ready to take her picture.”


“We would prefer that it is done portably. I have just placed her on high flow, and she is really short of breath. I am concerned that if we move her that she may deteriorate or worse.”


“Now, we don’t want ‘or worse’. I will mark that she is unstable and will ask the tech to perform the X-ray portably.”


“Awesome. Thank you!”


Alexa hangs up the phone and moves off to find Jackie and let her know.

Place: Medical Radiography

Serge, an X-ray technician, looks at Emily, the unit coordinator for X-ray and frowns. “She can’t come to the department?”


“Yes, that’s correct. The respiratory therapist (RT) says she is unstable and is concerned that she won’t do well being moved about.”


“Okay, I hope there is someone to help me out down there.”


“I am sure there is, Serge. Your back will be fine. You might want to think about a different sport to do on your days off. I saw the YouTube video of your rugby game that you posted. That game is violent; you took some pretty good hits.”


Serge smiles. “Yeah. My partner says the same thing, yet he comes to every game and cheers us on. I think he gets a kick out of seeing me being flattened on the field!”


Emily laughs. “I also like to see you flattened. Your expression after being run over is one of pure confusion, as in ‘How could this happen to me?’”


Serge chuckles. “Okay, I can only take so much ribbing here. I’m off to Emergency. Sharon and Preeti are the only ones in the department right now. They are in the back helping out in Room 2 with a chest tube insertion. You can page me if anything comes in. They will probably be busy for another 30 minutes or so.”


Emily nods her head and goes back to the computer.


Serge quickly heads out the doors and takes the back stairs to the Emergency Department. In the alcove by the back stairs in Emergency is the portable X-ray machine. He grabs an unexposed plate and places it in the cassette bin on the back of the machine. He then checks the charge and pre-sets a chest technique of 85 kvp (kilovoltage peak, the maximum high voltage applied to an X-ray tube in order to produce the X-rays) and 5 mAs (milliampere-second, a unit to measure the amount of radiation produced for an X-ray, over a second) before unplugging the machine. He navigates the X-ray machine to Miki’s stretcher. Looking at the requisition for the reason of the exam, he thinks to himself, “SOB. Not much of a history.” Driving the X-ray machine to the end of the bed, he pulls out the X-ray tube to point towards his client.


“Good morning, Ms. Huang.” While reaching to read her name band, he continues. “My name is Serge, and I am going to take a picture of your chest today.” Serge notes the large nasal prong Optiflow and then looks at the SaO2 on the screen and sees the number in the low 90s. “Okay, that is not bad, but not great,” he thinks to himself, “I can see why they asked for a portable.”


Miki weakly opens her eyes to see a very large man with a jet-black beard holding what looks to be a rectangular metal board. Panicked to see this stranger towering over her, her eyes dart around the room before she remembers that Linda left to use the restroom. “What is he here for? What is he going to do to me?” she thinks, mind racing.


Noting the patient’s wariness, Serge smiles broadly to reassure her. “Ms. Huang, I am going to take an X-ray of your chest. Dr. Notley has requested this test to help us help you.”


Still groggy and unsure of what is happening, Miki blurts out one of the only English words she knows: “No.”


Serge stops, a bit confused. “Don’t worry Miki, there is nothing to be worried about. This procedure is completely painless and super quick, too.”


“…No.” Miki tries to gesture towards where Linda headed, but Serge does not understand.


Just then, Linda barrels back into the room. “Hi hi! I’m here now I’m her daughter and translator oh my goodness I’m so sorry what did I miss?” she asks, breathless.


“This strange man is trying to do something to me, and I want him out right now,” Miki says to her daughter sternly.


Serge steps forward. “Hi, my name is Serge, and I’m here to take an X-ray of your mother’s chest as requested by Dr. Notley.”


“Oh, yes, of course, that makes sense. My apologies for my mother; she doesn’t speak English at all.”


“No problem…oh look, here is Jackie the nurse coming now. Jackie, can you help position Ms. Huang so we can get the best picture possible?”


Jackie smiles, “Would be happy to do so. Thanks for doing this portable. I am not sure that she would have tolerated going to the department.”


“We are a bit short-staffed today so it’s a bit of a stretch for us, but yes, I can see why you asked.”


Turning his attention back to Ms. Huang and Linda, he says to the pair, “We are going to get you sitting up straight in your stretcher. Looks like you’re high enough on the bed that we don’t need to boost you. Linda, I need you to tell your mom to breathe when I yell, and you just follow Jackie’s lead later, okay?”


Serge and Jackie position Miki into high fowlers and place the X-ray plate behind her back. “This is a hard board, but it won’t be for too long.” From the side of the stretcher, Serge reaches around Miki to make sure there is enough of the Imaging Plate (IP) on both sides of her and above her shoulders. “Please tell your mother to try her best to hold still.”


Serge walks back to the portable X-ray machine to adjust his pre-set technique to 90 kVp at 3.2 mAs to hopefully compensate for her SOB. “That should give a faster exposure,” he thinks. Meanwhile, Miki wiggles from the discomfort of the plate, and the IP slips down from where Serge had placed it. He does not notice.


“Okay, Ms. Huang, I’m going to take that X-ray now. Hold still.” Serge reaches for the lead apron hanging on the portable machine. He opens the collimation wide and adjusts the tube head to match his IP. Speaking very loudly, he calls out, “X-ray, Bed 3!” On cue, Jackie and all the other personnel scatter, with Linda in hot pursuit.


“Breathe in. Ms. Huang, take a breath in!” Serge watches her chest fall and rise and takes the X-ray on what he hopes is inspiration. “X-ray clear!” He pulls Miki forward on his own and slips out his plate. “I’ll sit you back a little. Let me know when…” He starts to bring her head down until she clenches his arm out of discomfort.


“Thanks Miki. I am all done now. Dr. Notley should have the result in a few minutes. Thanks to you too, Nurse Jackie.” Miki understands that they are finished for now and pats Serge’s arm gratefully.  Jackie scowls at Serge and lightly punches him. “Be careful now. I saw that YouTube video of you playing rugby. I could see me cheering-on the opposite team.”


Serge rolls his eyes. “Who hasn’t seen that video? It’s going to haunt me for a long time.”


“Ah, I’m sure one day it will fade into irrelevancy.”


Serge smiles and backs the portable X-ray machine away from the bedside table and navigates it back to the alcove. He plugs it in and readies it for the next use.


Opening the back stairwell door, he takes the stairs two at a time back to the department.

Place: Medical Laboratory

Jennifer, who was the lab tech on duty yesterday, checks the list of patients she was just handed by the unit coordinator. “Wow, I got Emergency again,” she notes to herself. “This is either going to be a good day or not.” Looking through the list, she sees the familiar name of Miki Huang. “I wonder how she is doing? I think I will go see her first.”


Jennifer pushes her white cart to the elevator and makes her way to the Emergency Department. Checking in at the nurses’ station, she confirms that Miki Huang is still in Emergency and that she is in the back area.


Jennifer proceeds to Miki’s bedside and looks behind the curtain to see the elderly woman sleeping. She is slightly surprised to see Linda still there, huddled on a stool and eyes filled with concern. Moving towards her, she touches Linda’s hand gently. “Linda?”


Startled, Linda looks up. “Oh, hi. I think I remember you. Sorry, I was lost in thought. Is S everything okay?”


“Yes, my name is Jennifer in case you have forgotten. Dr. Notley ordered some lab tests for you and I am here to draw them.”


“Oh, you’re the girl from yesterday, right?”


“That is correct. But what are you still doing here? You look so exhausted. Has nobody offered a translator? They should be here by now.”


Linda hesitates. “To tell you the truth, I’m just so used to always taking care of my mother that I don’t trust anyone but me to get the job done,” she says. “Especially where we’re from, children are always expected to care for their parents in old age. And I don’t mind it, it’s just that there’s going to be a lot of work for me to catch up on later.”


“Okay, Linda, I see. Well, you are more than welcome to stay and watch over your mother, and we certainly appreciate having someone so attentive and understanding of your mother’s needs,” Jennifer replies soothingly. “Now, I just need to check her ID band and ask a few quick questions.”


Jennifer checks the ID band against the requisition and the blood tube labels and sees that everything is correct. Miki, awakened by the conversation, lies back and observes silently.


“Can you tell me your birth date?”


Linda translates the question, before quickly conveying the answer back to Jennifer.


“Excellent. Can you tell me your middle name?”


Confused, Linda translates the question for her anyways and looks back to Jennifer. “She says she doesn’t have one, just like I thought?”


“Yes, that was a trick question. I need to confirm that you are who you are and not someone else. This makes sure that the test is done on the right person.”


Relieved, Linda nods her head. Jennifer wraps a tourniquet around Miki’s upper right arm. She assesses the brachial vein and sees it stand out after a few seconds. Nodding to herself, she reaches back into her cart and gathers the correct tubes. “This is going to feel like a pinch. Are you ready?” Jennifer quickly inserts the needle into the vein and fills each of the tubes. Releasing the tourniquet, she places a cotton swab on Miki’s puncture wound. “Linda, please tell her to hold it here. I just need to label these tubes.”


After labelling the tubes, Jennifer checks the site and sees no further bleeding. She places a small round band-aid on the site. “All good. You okay?”


“She says she’s doing fine for being locked up in this prison.”


Jennifer chuckles and nods, then turns to the cart and leaves Miki.

Time: 09h30

Dr. Notley approaches Jackie. “Okay, the medical team has accepted Miki Huang. Can you get her ready to go to the 7th floor? She will be under Dr. Honicutt’s team.”


“She is pretty well ready to go. I need to fill out her transfer assessment information and gather any belongings. She has been asking when she can get out of this noisy place.”


Dr. Notley smiles and turns to the unit coordinator. “Can you ask for a porter to help Jackie take Miki Huang to the floor please?”


“Glen will be back from Diagnostics shortly and he knows to check with Jackie about the next transfer.”


“Excellent. Okay, I am off to the triage desk to see who will fill that stretcher.”


“Thanks.” Looking at the unit coordinator, Jackie asks, “Can you hand me up one of those transfer assessment forms please?”


“Sure thing.”


Jacki takes the form handed to her, reviews the notes and Miki’s chart, and fills it out quickly, remembering to include the daughter Linda’s cell phone number and a quick note about the patient’s language barrier. “I will have to include that Linda is acting as translator at the moment too. Oh, and almost forgot- better find Alexa the RT so she can get the O2 tank.”


Jackie walks back to Miki’s stretcher to find Alexa already with a portable tank and setting it up.


“I was just going to page you to see if you knew about the transfer.”


“A little bird by the name of Glen let me know that this may be happening. I will go up with Glen and transfer my notes over to the floor RT so they know to check in on Ms. Huang often.”


Jackie smiles. “Glen always seems to know when things are happening. He’s the one who showed me the video with Serge taking that hit.”


“Ms. Huang, in a few minutes, Glen and Alexa are going to take you up to the 7th floor. You will be in a semi-private room, meaning that you will have one other person with you.”


Linda frowns, “Is there no way for her to get a private room? Will it be too cramped if I’m there too?”


“I don’t think that’s possible at the moment. Of course, I am aware that you’ll still be staying with her, and I’ll do my best to make sure that your mother’s stay runs as smoothly as possible.”


Just then, Glen comes around the corner. “All ready to go?”


“Yes, here is the transfer assessment, and Alexa will report to the floor RT. Let them know all the latest results are in the system. Here is her bag of meds. I have started the antibiotic, and it’s infusing on the pump.”


“Okay, sounds good. Leave her to us, she is in good hands.”


“Take care, you two.” Jackie watches as Glen pushes the stretcher out of the Emergency Room towards the patient elevator, with Linda scurrying behind. She notes to herself, “Ms. Huang doesn’t look too happy, but does look slightly better with some oxygen on. Okay, I wonder who will be taking her place?”


Jackie turns around and heads to the nursing station to find out who will be filling the stretcher.

Time: 10h30

Place: Medical Unit (Seventh Floor)

As the elevator doors open, Miki and Linda are greeted with a view that overlooks the city. Miki thinks to herself, “I haven’t seen the outside world in so long. My room better have a view like this.” Glen grunts as he pushes the stretcher over the gap between the elevator and the door. Alexa follows him as he weaves past visitors and other professionals waiting for the elevators.


At the nurses’ station, Glen announces that Miki is the patient from Emergency., Tracie, a new Bachelor of Science in Nursing (BSN) graduate, stands up from the computer screen. This is just her tenth shift on the seventh floor. “Hi Glen. Ms. Huang is going to be my patient. I have prepared Room 712 for her, and she will be next to the window in Bed 1.”


“Awesome. Okay Ms. Huang, let’s get you into your room.” Tracie assumes that the woman following near them is a family member.


Glen, with Alexa, Tracie, and Linda following him, pushes the stretcher part-way down the hall to Room 712. Sliding it easily past the patient in Bed 2, he maneuvers the stretcher right beside the bed and locks the wheels. Alexa and Tracie go to the other side of the bed and all three assist Miki to move across to her new bed.


Miki becomes breathless and keeps gasping for air. “Oh my god,” she panics silently, “I can’t catch my breath and I have no way of telling them.” It suddenly strikes her all at once how helpless she really is, which only intensifies her anxiety.


Since arriving at the hospital, Linda feels like she has not once taken her eyes off her frail mother. This is probably why she quickly notices Miki’s widened eyes and rapidly fluttering chest. “Hey, I think she’s having trouble breathing!” Linda yells from the side.


Although the English words don’t make sense to her, Miki is flooded with relief because she is reminded of her daughter’s presence. In the midst of her wheezing fit, she makes up her mind to buy Linda a present after this whole ordeal is over. Perhaps that phone Linda had been eyeing earlier in the month.


Alexa steps toward the bed and moves the oxygen tubing from the portable tank to the wall outlet. “Ms. Huang, I want you to try to take some deep breaths through your nose and blow out through your mouth. Slightly close your lips together like you are whistling.”


Linda quickly translates, voice trembling just the slightest at the sight of her mother struggling to breathe. Miki takes a deep breath in through her nose and breathes out through her partially closed mouth.


“Very good, Ms. Huang. Keep going. Another breath. Excellent.” Alexa watches the oximeter move from an SpO2 of 88% to 93% with Miki taking slow deep breaths.


“How do you feel now?”


Linda touches her mother’s arm gently, and Alexa watches the two of them converse with each other in their native language.


“She said she’s really tired but can catch her breath now. Thank you.” Miki reaches her hand out and pats Alexa’s gratefully. Alexa smiles back and pats Miki’s hand a couple of times.


“Ms. Huang, my name is Tracie, and I will be the nurse caring for you. I am going to step outside and review your chart so I can plan your care and then I will be back in a few minutes. Do you need anything right now?”


“She said her karaoke machine,” Linda says, rolling her eyes. Secretly though, she is thrilled that her mother is feeling well enough to joke around again.


Everyone in the room chuckles, then Tracie and Alexa step outside the room. Glen follows, pulling the stretcher out, only banging the wall lightly as he pulls it around the corner of Bed 2.


Alexa speaks. “Tracie? I have placed Ms. Huang on opti-flow and her Sats are pretty good when she does not exert herself. Orders are to keep Sats above 93%. I will talk with the RT covering this flow so they can come by and see her frequently.”


Tracie flips through the papers from Emergency including the transfer form. “Looks good. I do have one question though: why did you ask her to breathe through closed lips like whistling?”


“That is called pursed lip breathing. Some patients with COPD do it naturally. It helps keep the alveoli open and prevents them from collapsing and making her oxygenation worse.”


“Oh, I sort of remember that from school. I will have to look that up. Thank you.”


“Okay, if you need anything, please call the floor RT and they will come and help out.”


“Will do.” Tracie moves back to the desk to review the chart, lab work, and other tests. She notes that the antibiotics have started and the next dose according to the transfer form is in four hours.


“Okay, everything looks fine right now. I need to start the admission assessment.”


Tracie gathers the vital sign machine and her stethoscope, before heading to Miki’s room.


“Hi Ms. Huang, I would like to have a closer look at you and take your vital signs. Is that okay?”


“Mom, she’s just going to do a quick check up again, alright?”


Miki nods passively, and Tracie attaches the blood pressure cuff to Miki’s arm, places the pulse oximeter on her finger, and then inserts the temperature probe under her tongue. While the machine is humming, she looks critically at Miki and thinks to herself: “It looks like she is breathing a bit faster than normal, chest expansion seems symmetrical, and she has a bit of nasal flaring.


The vital signs machine beeps and Tracie records all the vitals onto the admission assessment.

Day: 1 Pulse Rate Blood Pressure Respiratory Rate Temperature O2 Saturation
 Time: 18h00 96 180/90 28 36.5° C 85% on Optiflow


“Ms. Huang, I need to lift up your gown a bit and listen to your heart and lungs.”


Linda gestures to her mother, who understands. She sighs and pulls her gown out from under her. Tracie systematically listens to Miki’s heart and lungs and records her findings along with the respiratory rate onto the admission assessment form.


“Thank you, Ms. Huang. I am almost done. Can you tell me your birth date, day of the week and who is prime minister?”


Miki answers each question in Taiwanese, and Linda conveys them back to Tracie in English. Tracie goes on to fully assess Miki and record her findings on the admission assessment form.


“Okay, thank you. I’m all done for now. Do you need anything?”


“She’s asking when lunch will be?”


“It should be coming up anytime now. I think I heard the lunch cart in the hallway so you should be getting it soon.”


“Thank you so much. She doesn’t need anything else at the moment.”


Around 15 minutes later, lunch is dropped off. Eyeing it, Miki is speechless. A plate featuring a single chicken breast is crowned with steamed corn and broccoli, along with a garden salad and yogurt on the side. Even in her weak state, Miki musters up the energy to complain.


“What is all this? How cheap do they have to be, serving breast meat? I don’t even have to taste it to tell you it’s dry.”


Linda cracks a smile. “Mom, this isn’t Taiwan. People love chicken breasts here and they’re actually more expensive than the thigh believe it or not. Plus, there’s lots of protein which is good for you.”


Miki rolls her eyes. “Yeah, sure. And I suppose they got too lazy to cook the vegetables? How dumb is this hospital, everyone knows that eating cold things aren’t good for organs. I swear they’re trying to make me sicker.”


“Um, I’m not sure if they have the same concepts as Chinese medicine about cooling foods but I can eat your salad for you?”


“Not a chance, are you trying to get pneumonia too? Neither of us will be touching this salad.”


Linda sighs, mentally preparing herself for a challenging (and hungry) few days.



This section has been from Health Case Studies by Glynda Rees, Rob Kruger, and Janet Morrison.


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Pathology Copyright © 2022 by Annabelle Liao is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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