7 Case Study: Meryl Smith Heart failure
Patient: Meryl Smith
Patient: Meryl Smith
Date of Birth: 06/06/19xx
PERSONA
Meryl Smith is 44 years old and she lives in a small two bedroom home with her partner, Dorothy. They co-parent two children with Meryl’s ex-husband. Her marriage to him ended four years ago. Meryl is a police officer with the Royal Canadian Mounted Police (RCMP). Meryl drinks occasionally, she has never smoked, and she is physically active. Meryl and Dorothy also have two cats at home with them.
Past medical history includes a heart murmur developed after her second pregnancy. She had a cholecystectomy three years ago and a laminectomy 14 years ago. She has recently been recovering from a severe flu.
Day: 0
Time: 09h30
Place: Supermarket
Dorothy looked over her shoulder at Meryl, who seemed to be trailing with the shopping cart . This is a bit unusual. Meryl hates food shopping and tries to complete it as quickly as possible, she thought.
“Meryl, you doing ok dear? I think we are out of mayo. Can you grab the low fat, small jar as you walk past?”
Meryl looks up at Dorothy and smiles weakly. “I am feeling a bit tired, but I’m ok. Yes, I’ll grab the mayo, but I’m getting the one that is on sale.”
Meryl reaches up and grabs a small plastic jar of mayo and places it in the top part of the cart.What the heck is going on? I really don’t feel so well and Dorothy is walking so fast today. She usually likes to shop, she thought.
Dorothy waits for Meryl at the end of the condiment row and rubs her back and gives her a quick peck on the cheek before moving off again down the next row. Meryl, taking a deep breath and leaning heavily on the cart, plods slowly forward.
Time: 10h00
“Meryl, where are you?” Dorothy does a 360 degree turn in the row and does not see her spouse anywhere. She quickly checks the next row only to see it empty. Feeling a bit panicked, like losing a child, Dorothy retraces her steps to the previous row to find Meryl, sitting on the floor with the partially full cart a few feet down the row.
Rushing up to Meryl, Dorothy quickly looks around and then bends down. “Did you fall? Are you ok?”
Meryl looks up slowly and Dorothy immediately recognizes that something is not right.
“Oh my, Meryl, you do not look good. You are pale and quite dusky looking. I’m not quite sure you are over the flu.”
“Dorothy. I am not. Feeling good. Not the flu. Very dizzy.” Meryl whispers breathlessly. “I think it’s….My heart.”
Dorothy goes into full panic mode on hearing ‘heart’. She helps Meryl stand; Meryl wobbles a little bit before seeming to settle on her feet. Together they walk out like a coach guiding an injured player from the field.
“Dorothy… our cart!”
“Meryl, the least of my concerns is the cart. Someone can put the stuff back on the shelves. I am more concerned about you. We are going to the Emergency.”
Meryl places both hands on the roof of their small sports car and waits for Dorothy to open the door. “What if I. Don’t want to. Go to the Emergency?”
“Sorry, hon. Laying in the middle of Safeway examining the floor tiles closely, gets you one free express ticket to the Emergency. Don’t gripe. You are going to suck it up.”
Meryl allows Dorothy to help her into the passenger seat. Dorothy hears a bit of quiet grumbling from Meryl but chooses to ignore it.
Dorothy starts the car and backs out quickly. Driving faster than usual, Dorothy navigates the two of them through the back roads and into the parkade of the hospital.
Time: 10h30
“See, Meryl? This was meant to be. Someone left us a wheelchair to use.”
“You can’t be serious.”
“Try me, hon, you are riding until they tell me what is wrong with you.”
Dorothy guides Meryl out of the sports car and into the wheelchair. Pushing the wheelchair by the parking meter, Dorothy stops and pays for four hours of parking.
Emergency Room
Day: 0
Time: 11h15
Place: Emergency Triage
Nurse Jackie thinks to herself, Wow, I finally get to sit for a minute. This flu season has been brutal. Fifteen patients before 10:30 in the morning. She completes a number of stats forms behind the triage desk and adds some names to the whiteboard to keep track of where patients and staff are located.
Turning back to the desk, Jackie looks up to see two well-dressed, middle-aged women approaching, one in a wheelchair.
“I bet this is another flu case,” Jackie says to herself.
“Good morning, can I help you?”
Dorothy pulls the wheelchair up to the triage desk. “That is why we are here, for you to help us or more specifically help Meryl!!”
Jackie looks at both women and attempts a smile. Ok, this could be challenging, she thinks.
“What seems to be the problem or what can I help with?”
“My name is Dorothy and this is my wife, Meryl, who happened to pass out at Safeway this morning while we were shopping.”
“My name is Jackie and I am the triage nurse or the nurse that looks at you first to consider how serious your problem is. Ok, so you passed out? Did you lose conscious or did you become dizzy and just sink to the floor?”
Meryl looks over at both of them. “I think a little of both. I just remember coming to, sitting cross legged on the floor.”
“Ok, seems you are a bit short of breath?”
Meryl tries to take a deep breath that only results in a weak cough. “Yes, getting over the flu. Thought I was over it.”
Jackie steps out from behind the triage desk and brings the vital sign machine with her.
Hooking Meryl up to the blood pressure cuff and the pulse and temperature, she presses a button to initiate the machine to take Meryl’s vital signs.
| Day: 0 | Pulse Rate | Blood Pressure | Respiratory Rate | Temperature | O2 Saturation |
| Time: 11h20 | 106 | 95/60 | 20 | 36.5°C | 95% |
Nurse Jackie looks over the results and sees the temperature is not elevated, but the blood pressure (BP) is down and the heart rate (HR) is up. “Doesn’t look like it’s the flu for you, but maybe something else. Ok, let’s get you to wait over there and I will see if we can get someone to see you shortly. It’s not too busy so it should not be long.”
Dorothy shakes her head. “Wonderful — our health system at work. Ok Meryl, we get to sit and wait.”
Meryl looks up at Dorothy. “I am ok to wait.”
“You might be but I am not.” Dorothy directs the chair over to where Jackie indicated.
Time: 11h30
Nurse Jackie approaches Meryl and Dorothy. “I need to take some more information and then we can get you seen by the doctor.”
Jackie takes a full health history from Meryl asking her about past history, medication, allergies, and contact information.
“So you have a heart murmur that didn’t go away after your last pregnancy?”
“Yes, they told me not to worry too much about it.”
“Did they tell you anything more?”
“No, I haven’t worried about it till now. Today my chest just feels different and I am short of breath.”
“Ok, thank you. I am going to talk with Dr. Smythe and we will move you to another area here so we can explore more fully what is going on.”
Jackie walks away to find Dr. Smythe.
Time: 12h15
Just as Jackie is finishing recording her findings, Dr. Smythe approaches the bedside.
“Hello, my name is Dr. Edward Smythe. I am one of the Emergency physicians and Jackie asked me to take a look at you.”
Both Meryl and Dorothy look up and smile at Dr. Smythe and nod their heads together.
Dr. Smythe begins to assess Meryl, turning her head back and forth looking at her neck. He then checks her fingers and then looks at her ankles and gives them a bit of a squeeze. “I need to listen to your heart and lungs.”
Meryl adjusts her blouse to allow Dr. Smthye to access her chest. Dr. Smythe listens carefully to heart and breath sounds.
After completing his assessment, he steps back and looks at both Meryl and Dorothy. “I don’t think it’s the flu. Your heart murmur is quite loud, much louder than I expected, and you have quite coarse breath sounds. I believe I am also hearing an extra heart sound. Now this could be nothing or it could be serious so I would like to do some blood work, and a chest X-ray. I am also going to ask for a pregnancy test since the heart murmur appeared with your last pregnancy.”
Dorothy laughs. “Doctor Smythe, I don’t think she is pregnant!”
“Still it did happen and we need to rule it out.”
Dr. Smythe turns to Jill. “Please place her on the monitor and take vital signs q 15 minutes for the next hour then q1h. I will order a CBC, lytes, BUN, creatinine, trops, 12 Lead, and a portable chest X-ray.” Also, glucose, urinalysis, and a pregnancy screen. For the time being you’re on bed rest, and I will ask Cardiology to come see you.”
Jill records all this to make sure nothing gets missed.
Dr. Smythe turns back to the two women. “Meryl, you are going to be spending the better part of the day with us, so I am going to admit you to the Emergency and after we have all the tests results back, I will come and discuss these with you and what our next steps are.”
“Thank you, Dr. Smythe.”
Time: 12h45
The phone rings beside Jill as she is charting another episode of atrial fib, “Hello, this is Jill.”
“Hi Jill. This is Gurpreet in Radiology. I have a requisition for a chest X-ray on a Mrs. Meryl Smith. Can she come to the department?”
“I am thinking not as I have her on the monitor, and she was admitted with a complaint of loss of consciousness. I am a bit concerned that if she goes out, something may happen. I or another nurse will need to go with her.”
“Ok Jill, I thought that might be the case but I thought I would ask. I’ll be down in a couple of minutes and will do her X-ray with the portable in Emergency.”
“Thanks.” Jill hangs up the phone, finishes scotch taping the rhythm change to the patient’s chart and moves to Meryl’s bedside.
“Hi, Mrs. Smith. They’re coming down to do a chest X-ray so I would like to help get you setup so you’re ready for it when Gurpreet arrives with the machine.”
Jill then helps Meryl sit up straight, moves the ECG leads off her chest, and explains the X-ray to both Dorothy and Meryl.
Just as she is finishing, Gurpreet comes around the corner pushing the portable x-ray.
“Man, these things never get any lighter! Even with the power drive they’re a challenge to move around without running on toes. Is this Mrs. Meryl Smith?”
Jill smiles and looks at Gurpreet, “Yes it is, and that was quick. Do I need to check the wheels for any toes?”
“No, heard a couple of screams but nothing else as I drove here. Thank you for getting everything setup for me.”
“No problem.”
Gurpreet moves to the bedside, and checks Meryl’s position. “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.”
Meryl nods her consent.
Gurpreet looks at the requisition, and compares the information to the ID band on Meryl’s left wrist. “Can you tell me your birth date?”
“Yes it is June 6, 19xx.”
“Ok, we are good to go.”
Gurpreet returns to the portable X-ray and withdraws from the rear hidden compartment, a large board. Slipping the board into a special plastic bag, she returns to the bedside. With Jill’s assistance they both lean Meryl forward and place the X-ray board behind her back.
“Oh, that is so uncomfortable.”
“Its only for a couple of minutes. Relax against the board and try not to move.”
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 Meryl’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 to Jill and grabs a lead apron from the stanchion of the X-ray machine.
“X-ray ready in Bed 4.
“Stand clear, X-ray exposing Bed 4!” Gurpreet then presses a button which starts a whirring sound, ending with a dull click.
“Ok, all done Mrs. Smith.” Gurpreet hangs up the lead apron on the stanchion and moves to the bedside to help Jill remove the board and reposition Meryl into a more comfortable position.
Gurpreet backs the portable X-ray machine out.
Dorothy returns at the same time from grabbing coffees for her and Meryl. “Hey, what did I miss?”
Jill turns and says “First of many tests we have to complete. That was the X-ray and I’m hoping the lab person will be by shortly as well for the other tests.”
Time: 12h59
Alexa looks at the list of requisitions that have come into the lab. “Alright, there is a bunch from Emergency and two from the Family Birthing Unit. I can do the Emergency ones quickly. I should see if someone can do the FBU ones.”
Looking up, she sees Harry at the desk. “Hey Harry, can you do me a favour? I am a bit swamped with reqs from Emergency and there are two from the FBU that I can’t do as quickly as they would like. Do you mind?”
Harry smiles, “For you Alexa, anything, but it will cost you a coffee.”
“A coffee I can handle, thank you.”
Alexa grabs her lab cart and heads out the door to the Emergency Department. While waiting in the elevator she, looks over the reqs for Emergency. Ok, she thinks. Nothing special. Appears to be more routine with no stats. Let’s start with the oldest time stamp and work my way to the recents.
Time: 13h14
Alexa: “Good day, are you Mrs. Meryl Smith?”
“Yes, why do you ask?”
“My name is Alexa and the Emergency physician ordered some lab work for you.”
“Ok.”
Alexa looks at the requisition, compares this to the labels and then attaches the labels to the appropriate tubes. That done, she approaches Meryl’s bedside. “I need to ask you some questions to ensure that I have the right patient and the right lab work ordered.” Alexa sees Meryl nod. “Ok, can you tell me your full legal name?”
“Meryl May Smith. My birth date is June 6, 19xx.”
“Oh, you have been practicing.”
“Not really, everyone seems to ask me the same questions.”
“True, we need to make sure we have the right patient and the right tests. We try to avoid making an error as much as possible.”
Alexa, prepares for the venipuncture by gathering all the correct equipment. She then wraps a tourniquet around Meryl’s left arm. Carefully examining her ACF she finds a large prominent vein. “You may feel a bit of a pinch.”
Alexa then slips the vacu-container needle quickly into the vein and seeing a flashback of blood pushes the first tube down into the vacu-container. She repeats this three more times to fill all four collection tubes.
“Ok, Mrs. Smith, please hold here.” Meryl does as requested. Alexa rechecks the labels against the requisition and then places the tubes in their racks for processing .
“Now, lets put a bit of a band-aid on that and then I will leave you be. I hope everything turns out ok for you, Mrs. Smith.” Alexa then pushes her cart out into the main part of the Emergency Department. Ok, that’s all the patients, she notes. I’ll take these samples back for processing and then see if anyone needs help.
Time: 13h20
Jill approaches Meryl’s bedside just as the ECG technician arrives. “Is this Mrs. Meryl Smith?”
Jill looks up and sees the 12 lead cart. “Yes it is.”
“Ok, thanks, it has been a bit hectic. Sorry, I’m running a bit late.”
Jill shrugs and checks the monitor and writes down the vital signs.
| Day: 0 | Pulse Rate | Blood Pressure | Respiratory Rate | Temperature | O2 Saturation |
| Time: 13h20 | 104 | 98/60 | 22 | 36.5°C | 95% |
“Hi Mrs. Smith, I’m Denis and I am going to place some wires on your chest, legs and arms. This will then give us a better view of your heart electrical function.”
“Ok, I guess.”
Denis pulls the curtains closed to give Meryl some privacy and then requests she lift her shirt up a bit so that he can place the wires on the left side of her chest. Efficiently he quickly places the leads on Meryl’s chest, legs, and arms. About a minute later the machines is printing out a 12 lead ECG.
“Now that you have all those squiggly lines on pink paper, who looks at it and what does it all mean?” asks Meryl.
Denis smiles, “Well I give one copy here to Jill for your chart and another copy goes with me for the heart doctor to look at. Whoever the heart doctor is, will then dictate a report that goes on your chart.”
“When will I know what it says?”
“I would guess pretty soon, but that is up to Jill and the Emergency doctor.”
Meryl sighs and lays back.
Denis pulls the curtains back and passes the 12 lead to Jill.
“Ok, Jill, here you go. I’ll let you discuss it with the Emergency doctors. I need to get up to the fifth floor for a stat.”
“Thanks Denis.”
Time: 14h30
Jill finds Dr. Smythe reviewing the chest X-ray, labs, and 12 lead of Meryl.
“What do you think, Dr. Smythe?”
“Well, it’s not great. Mrs. Smith has some congestion in her lungs, but has no fever, a little rise in WBC, and no signs of infection so I think the congestion is cardiac in nature. When I look at her 12 lead, I see some left ventricle enlargement. Her lab work is interesting as she has decreased kidney function according to her GFR and creatinine, plus, she has an elevated BNP. All other cardiac markers are normal. So, it appears she has exacerbation of heart failure.”
“Wow, she is very young to have HF.”
“Yes, but the valve issues she had when she was pregnant have not gotten better and it appears may have worsened over time. Is her wife here? I would like both of them to hear this.”
“Yes, Dorothy is with Meryl now.”
Jill leads Dr. Smythe to Meryl’s bedside.
Dr. Smythe looks at both women. It just never gets easy to give bad news; I so wish there was another way, he thinks.
“Ok, Mrs. Smith, I believe I know what is wrong with you and why you are not feeling well. I have reviewed all your lab tests and it points to a diagnosis of heart failure.”
“What, what is that, am I going to die?”
“Heart failure is a broad diagnosis indicating that your heart is not pumping as well as it should. For you, it is related to the valve issues you had when you were pregnant. The valve is not closing as well as it should and this is putting strain on your heart to meet your body’s need. No, you are not going to die right now. This is a serious diagnosis and needs to be managed well by you and a cardiologist.”
Dorothy begins to cry quietly at the bedside. Meryl reaches over and holds her hand. “Ok, Doctor, what happens now?”
“I am going to contact the cardiology team. I would like to admit you under their care so that they can get you on the right meds, provide some teaching for you and your spouse, and get you involved with some support groups to help you cope with this. I know it’s a lot to take in, but with proper management you should be ok.”
Meryl, looking overwhelmed, looks back at Dorothy then at Dr. Smythe and Jill. “I’ll do what ever you ask.”
Dr. Smythe backs away from the bedside and walks toward the main nursing station to call the cardiology team. Jill approaches both Meryl and Dorothy. “Do you have any questions?”
“No. Can you leaves us alone for a little bit?”
“I certainly can. I’ll draw the curtains to give you a bit of privacy. I’ll come back in 15 minutes and get you ready to go upstairs to the fifth floor.”
Time: 15h30
Jill looks up at Meryl’s monitor and sees that her oxygen saturation is decreasing, now reading 88% on room air.
| Day: 0 | Pulse Rate | Blood Pressure | Respiratory Rate | Temperature | O2 Saturation |
| Time: 15:30 | 106 | 96/60 | 22 | 36.5°C | 88% |
“Hi Meryl, are you feeling ok?” she asks.
“No, I feel short of breath, can’t catch my breath. Feels like I have been running.”
Jill notes that Meryl’s heart rate is also increasing but still sinus.
“Ok, I think I am going to have to put some oxygen on you.” Jill frees a set of nasal prongs from their plastic bag and plugs one end into the oxygen flowmeter. She wraps the other end around Meryl’s ears and places the prongs gently in her nose. Jill adjusts the oxygen flow to 4 LPM.
“Ok, Mrs. Smith. Take some deep breaths through your nose and blow out through your mouth.”
Meryl takes a half dozen breaths as instructed and Jill notes the sats improve to 93% and the heart rate beginning to decrease to 95 to 100 beats per minute.
“Thank you, I feel a bit better but not normal. Am I getting worse?”
“Maybe, but it is too early to tell. Let’s just say you need a bit of oxygen, but nothing else has changed.”
“All right.”
Jill leaves Meryl alone and goes to find Dr. Smythe
She finds Dr. Smythe coming out of the dictation room with a cup of tea in his hand.
“Dr. Smythe, Mrs Meryl Smith is now requiring oxygen and she is stating she is not feeling quite right and is short of breath.”
“I thought this might happen. Ok, I am going to order a transthoracic echo and I will call Cardiology to take her as soon as a bed is available. They said they are discharging eight patients today so there should be space for her.”
Jill watches Dr. Smythe fill out the stat requisition for a cardiac ultrasound.
Time: 16h00
Charlie reviews the requisitions on the computer screen. What is this: stat echo in Emergency? he wonders.
Reading the information on the echo requisition, he notes that a consult to Cardiology has also been requested.
Grabbing the phone, Charlie calls Emergency and asks for the nurse caring for Mrs. Meryl Smith.
“Hello this is Jill.”
“Hi Jill this is Charlie in Echo. I have a stat req for Mrs. Smith. Can she come to the department?”
“I am not comfortable sending her to you. She is on oxygen and is monitored. She is now experiencing shortness of breath and is not feeling quite right. This is her first experience with heart failure and we’re not sure how she is responding right now.”
“Ok, I will bring a portable machine down. It won’t be ideal, but I can help add to the information on the patient. Most likely she will need a second echo in the department to get better pictures, but I will leave that up to Cardiology. I will be there in about 10 minutes.”
“Thanks Charlie.”
Time: 16h10
Charlie, true to his word, arrives pushing a large ultrasound machine in front of him. Slightly out of breath from having to push the machine and avoid all the activity in the Emergency Department, he maneuvers the machine close to Meryl’s stretcher.
“Hi Mrs. Smith, my name is Charlie and I am an echo cardiology technician. I’m going to take some moving pictures of your heart. It won’t hurt, but may be a little cold as I have to use some gel.”
“I remember having one of these when I was pregnant.”
“Meryl, I’m going to step out and update the family while Charlie does his test thingy. There’s not much room for me and his machine. I will come back.” Dorothy moves around the echo machine and heads to the waiting area to make some phone calls.
Charlie pulls the curtains around Meryl’s bedside and turns off the lights by the bed so it’s a bit darker and easier to see the echo machine’s screen.
“Ok, Mrs. Smith. You are going to need to pull your gown up a bit so I can see the left side of your chest.”
Meryl exposes the left side of her chest and Charlie adjusts the gown to cover most of Meryl’s breast.
“The gel is warm, but not really warm so it may feel a bit cold to you. I’m going to squirt some on your chest and on the probe. This helps us get a better picture.”
Meryl shudders a bit as the gel is placed on her chest and then relaxes as Charlie places the probe over her tricuspid area.
“Ok, Mrs. Smith, I am done with the echo.”
Charlie takes a towel and carefully removes as much of the gel as possible and then helps Meryl readjust her gown.
“What did you see? It looks like it was all shadows to me.”
“I can tell that your heart is not pumping as well as it should and that you have a problem with one of your valves on the left side of your heart. Anything more will be up to the doctors as I cannot tell anymore than that.”
“Not sure I needed this test as you just said the same thing as Dr. Smythe.”
Charlie smiles, “Yeah? Well it confirms what he told you then.”
Pulling back the curtains, Charlie navigates the ultrasound machine out of the space and waves goodbye to both Jill and Meryl.
Time: 16h30
Jill sees that Dr. Smythe is talking with Charlie and walks closer to hear what they are saying.
“Ok, Charlie tell me again what you saw on the ultrasound?”
“Right. The ejection fraction is estimated at about 30%. Her LV looks a bit dilated. The mitral valve is graded a moderate regurg. On the plus side, I did not see any vegetation.”
Dr. Smythe looks over at Jill. “This is much worse than I expected. I am quite surprised she was managing so well in the community and this is her first time admitted with HF.”
Jill nods, “There’s a bed available for her on the fifth floor. They told me I could move her after 4pm.”
“Well, given everything we know, that is the best place for her. Thanks Charlie. Say hello to your dad for me and tell him, when he wants another bowling lesson, I’m available.”
“Thanks Dr. Smythe. I’m pretty sure my dad is still recovering from that perfect game you threw the last time you were out together. He may not want a lesson for awhile.”
Charlie smiles at both Dr. Smythe and Jill and with a wave moves off to grab his ultrasound machine.
“Ok, Jill, I don’t think I need to speak to Mrs. Smith again. Let’s get her upstairs and let Cardiology manage her. That would be best. I’ll finish writing the progress note and her orders to date. Cardiology will need to add their specific treatment.”
“Right. I will phone up report to the fifth floor and then take her up after 4pm. Thanks, Dr. Smythe.”
Time: 17h15
“Ok, Mrs. Smith,” Jill says, “They are ready for you on the fifth floor and they have a real bed in an actual room for you. Dorothy can come with us. I’m going to attach your leads to a portable system and have Glen the porter help me with your stretcher.”
Both Dorothy and Meryl look relieved that there is a real bed ready.
Jill grabs the portable monitor system and places it at the end of the bed. She then pulls out of the main monitor the cartridge with all of Meryl’s leads and information, and slides it into the portable system. Looking at the smaller screen, Jill makes some adjustments and nods satisfactorily that everything looks good.
Jill calls the front desk and asks for Glen the porter to help her with Mrs. Smith.
Glen arrives a few minutes later and together, with Dorothy’s help, they get Meryl up to her room on the fifth floor.
Day 0: Medical Ward
Day: 0
Time: 17h30
Place: Medical Ward
“Hi Jill, how are you doing? Is this Mrs. Smith?” asks Simone.
“Hi Simone, yes this is Mrs. Smith. Did someone pass on my phone report to you?”
“Yeah, I got the message. Do you have the transfer note and orders?”
“Here is the transfer note summarizing the care thus far and here is Dr. Smythe’s transfer note and his orders,” Jill says as she hands over the information. “He knows you will change them to support Mrs. Smith better.”
Simone carefully reads through Jill’s transfer note. “So she has had all her diagnostics but no cardiac meds?”
“That is correct.”
“Ok, I’ll get the team to see her as soon as we have her settled.”
Simone, Jill, and Glen maneuver the stretcher into a semi-private room and help Meryl transfer to the bed near the window. Jill takes the cartridge out of the portable monitor and slips it into the monitor above the bed. Watching carefully, she sees the monitor boot-up and display Meryl’s vital signs.
| Day: 0 | Pulse Rate | Blood Pressure | Respiratory Rate | Temperature | O2 Saturation |
| Time: 17h30 | 110 | 90/60 | 22 | 36.5°C | 95% with 4 LPM |
“Is this more comfortable than the stretcher?” Jill asks Meryl.
“Most definitely. Thank you.”
“Glen, can you hook up the nasal prongs to oxygen at 4 LPM please? Great, thank you.” Jill then turns to Dorothy and Meryl, “Mrs. Smith, it was a pleasure to meet you and I hope everything turns out well for you.”
In unison both Dorothy and Meryl thank Jill for her assistance.
Glen and Jill reverse the stretcher and head out the door. Jill checks in with Simone before she leaves. “Simone, do you need any more information or are you good?”
“Family aware?” asks Simone.
“Yes, Dorothy is the wife and she has been updating siblings. I have had no contact with any other family. Dorothy was stressed on admission, but seems to have settled right now. They seem to be good people with what appears to be bad luck.”
“Ok Jill, thanks. If anything crops up before the end of the shift, I’ll call you.”
“Sounds good.”
Both Glen and Jill wave and head to the elevators to get back to the Emergency Room.
Time: 17h45
Simone approaches the nursing station and sees the Cardiology team sitting at the small conference table in the middle of the nursing station.
“Hi Dr. Grant, Meryl Smith has just arrived from Emergency. She is the newly diagnosed heart failure patient.”
“Yes, I was talking with Dr. Smythe about her. Have they started any cardiac meds?”
“No. They have left that to you and the team to start. Essentially she has had all her diagnostics done, but no interventions. She is stable right now. On 4 LPM nasal prongs. Sinus rhythm. I haven’t done an assessment yet and wonder if we should all go in and talk with her and her wife.”
“I think that’s a great idea. We will be there in a couple of minutes. Simone, please go in and let her know she will have the team come and see her shortly.”
“Excellent. Will do.”
Simone heads to Meryl’s room to let her know the plan.
“Hi Mrs. Smith, my name is Simone and I’m one of the cardiology nurses that will be caring for you while on the unit. In a few minutes, the cardiology team will be in to assess you and ask you a few questions. We are going to do our assessments together and this way we coordinate our care and plan the best approach for you, and you get to ask any questions you have. Does this sound ok?”
“It’s a bit overwhelming.”
“I understand that. It is a lot to take in. Remember we are here to help you get better.”
“I realize that. It’s just so new.”
Dr. Grant then enters the room with the cardiology team.
“Good afternoon Mrs. Smith! My name is Dr. Neal Grant and these people behind me compose the cardiology team.”
“I’m Dennis, a senior resident.”
“I am Haley, the cardiology pharmacist.”
“I’m Harjinder, the junior resident.”
“I am Addy, the dietician for cardiology.”
“Ok, now that is a lot of names right now. We would like to get to know you a bit better, have a listen to your heart and lungs, and then plan out the interventions that will make you feel better than you do right now. How does that sound?”
Both Meryl and Dorothy nod but look a bit shy with six people standing around the bedside.
Dorothy asks, “Do you need me here?”
Dr. Grant nods. “I would like you to stay here so you can get the same information and it helps us learn about your wife. You are integral to her care especially when we send her home which I hope is a couple of days from now.”
Dorothy smiles at that but stands up and moves away from the bedside to give the cardiology team more room.
Dr Grant begins by asking general health questions, about activity levels, and then steps forward to listen to Meryl’s chest. Haley asks about medications at home, both prescribed and over-the-counter. Addy inquires about diet and activity. The two residents follow Dr. Grant’s lead and perform a physical assessment.
After 30 minutes of questions and assessment, Dr. Grant steps to the end of the bed “Ok, I think that is all for now. What I would like to do is start you on some medications. A beta blocker to slow your heart beat a bit so that the heart can fill better, an ace-inhibitor to decrease your blood pressure and then a drug to make you urinate a bit more to get rid of the extra fluid you are carrying around. These are common medications for patients that have your type of disease. They are also powerful medications and can cause you to be dizzy or not feel like yourself which is why we are going to keep you here to monitor you and make sure you are stable on the meds before going home. You will know they are working when you do not need oxygen any more. Do you have any questions?”
“No, but it’s a bit much to take in right now. Dorothy?”
Dorothy nods. “I agree with Meryl. Let’s just sit with what you have told us and maybe we’ll have questions later.”
“That sounds good. I am on call all this week so you will see me each morning during rounds. Please ask any questions then or ask Simone here or another member of the team. We are all here to make sure you get better”
Dr. Grant then turns and leaves the room followed by the team and Simone.
In the nursing station, Dr. Grant facilitates a debrief of everyone, which leads to each making their own notes in Meryl’s chart and Dennis writing the orders for the medications that Dr. Grant talked about.
Day 1: Medical Ward
Day: 1
Time: 08h00
Place: Medical Ward
“Good morning, Mrs. Smith. Do you remember me from yesterday. I’m Simone?”
“Yes, Simone, I remember you from yesterday. I see you’re back. This your second day shift?”
“Yes, this is my second. I am doing three days and a night shift this week so we will probably have one more day together. I have your meds here: a beta blocker, ace-inhibitor, and diuretic. But before you take these, I need to check your morning weight and your blood pressure. This is something you’re going to have to do each day on your own.”
“Ok, do you need me to do anything?”
“Nope, just lie back and relax while I take your BP and weight.”
Simone then presses a button on the bed to get Meryl’s weight and then presses the NIBP button on the monitor.
| Day: 1 | Pulse Rate | Blood Pressure | Respiratory Rate | Temperature | O2 Saturation | |
| Time: 08h00 | 65 | 90/55 | 18 | 36.5°C | 95% 3 LPM |
“Your blood pressure is down to 90/55, which is what we expect. Your heart rate is around 65, which is also what we expected. You have lost 1 kg of fluid since we started the diuretic, which is a bit less than we expected. How are you feeling when you stand at the bedside or use the commode?”
“I feel a bit lightheaded but nothing really serious, I don’t think.”
“Your oxygen has been dialed back to 3 LPM, but is not really changed. I would like to listen to your chest, then I will give you your meds and morning tray.”
Meryl adjusts her gown so that Simone can listen to her heart and lungs. Simone methodically moves through a head to toe assessment and records her findings.
“All done, Mrs. Smith. Here are your pills as we discussed and your breakfast.”
“This is it for breakfast? Some cereal, skim milk, and a couple pieces of fruit?”
“Yes, Addy the dietician you met yesterday has ordered for you the cardiac diet low in sugar and salt. She will be coming by later this AM to discuss diet with you and hopefully Dorothy. Diet is very important in heart failure and knowing more about how food affects your condition will help keep you out of the hospital.”
“Ok, this will take some getting use to. I really like my sausage and eggs for breakfast.”
“I can honestly say me too, but for you the rare sausage or eggs will be ok, just not every day. But Addy would be best to ask.”
Simone heads out of the room to check on her other patients. Meanwhile, Meryl picks up her spoon and moves the cereal around but really does not eat anything other than the half apple and tea on her tray.
Time: 10h30
“Hello, Mrs. Smith. My name is Addy and I am the dietician for Cardiology. We met yesterday with the rest of the team. You are Dorothy right? Mrs. Smith’s wife?”
Dorothy smiles. “Good memory, yes I am.”
Meryl looks up, “You’re probably here to discuss what I can or cannot eat?”
“That is correct. For you, diet and activity are going to be very important to maintaining good health and keeping you out of the hospital.”
Dorothy looking unhappy and says: “I suppose I’m here to learn as well so that I keep her on the straight and narrow path.”
“Yes, in my experience and in the research: when families are closely involved in the care of a loved one, the care is much more effective. The diet is not all bad, and you and Mrs. Smith will learn how to adapt it to your likes, but there are some things to consider.”
Addy sits at the bedside and hands both Meryl and Dorothy a sheet of do’s and don’ts for heart failure patients along with some sample menus and some links to recipes.
“It is really important that you consider low sodium foods and not adding any additional salt when cooking. Adding salt can lead to further water retention, which can stress your heart and make it not pump as well as it should.”
“Look, Meryl, many of the menu items we already eat. I just need to not add salt.”
“That is correct, Dorothy. Many patients find they are already cooking similar diets. I recommend that you not have a salt shaker on the counter or on the table. That way you’re not tempted to add salt. Look for fresh herbs and spices to add that kick of flavor we all desire. Things like garlic, cilantro, or sage can add some additional flavor to something like a broiled chicken breast.”
“Oh Meryl, we have always said we wanted a herb garden. I guess this will be the encouragement we need to start.” Dorothy’s eyes light up a bit more. “I can go shopping for the stuff we need and when you come home we can start planting.”
“Dorothy, this is not an excuse to go shopping. You always get so excited about things. We need to take this slowly. A garden is a good idea, but let’s start buying and cooking first.”
Dorothy’s eyes shine a bit less brightly, but she nods.
“Ok, you both look like you understand what I am asking you to do,” says Addy. “I would like you to look through the information I have given you. If you have any questions, write them on the sheets and I will come back tomorrow to see how you’re doing. The meal trays you get will be example meals that you should consider making at home. Dorothy, I need you not to bring anything extra in from home until Mrs. Smith is stabilized. Do you think you can do that?”
“I was just thinking of picking her up a milkshake, but I guess that’s out of the question?”
“Yes, until we have things more stabilized and the medications working well, that is for the best.”
Both women nod. Addy gets up and waves good bye to both Dorothy and Meryl, and heads out of the room to see the next patient on her list.
Time: 11h00
Simone stops Addy a couple of doors down from Meryl’s room. “How did your talk go?”
“Pretty well. They are both intelligent and are ready to learn. They seem less overwhelmed than yesterday. Meryl seems to be feeling better, but is still on oxygen. Dorothy was very excited about making a herb garden. All good signs.”
“Awesome, thanks. If they have any questions are you coming back today?”
“No, I think they will need to digest what I gave them. I said I would be back tomorrow to see how they are doing and to answer any questions.”
“Sounds good.”
Time: 11h15
“Mrs. Smith, how are you doing? I am back to do another ECG heart tracing on you.”
“Ok, and you are?”
“I’m Denis. I performed the test yesterday. Do you remember?”
“Oh, there was so much happening, I’m so sorry ,I can’t remember everyone’s name that is helping me.”
“That is quite all right. Ok, this test involves me placing some sticky tape on your arms, legs, and chest.”
“That I remember.” Meryl re-adjusts her gown so Denis can place the leads on her chest and arms. Denis pulls the covers up, leaving Meryl’s feet exposed so he can place the leads on each foot. “All done with that. I now need you to stay very still while we do the test.”
Denis pushes the button and the pink coloured paper is slowly pushed out of the machine with the squiggly lines from each of the 10 leads.
“All done.”
“Is there any change?”
“Mrs. Smith, I see lots of patients every day and my apologies. I cannot remember your test from yesterday. All I can say from looking at the ECG is that there is nothing to be done right away and you are not in danger right now.”
“I guess that’s a good thing, thanks.”
Denis prints out a second copy as an interim report for the chart, then removes the leads and stickies from Meryl’s body. “I’ll see you tomorrow.”
Meryl waves him goodbye.
As Denis is exiting the room, Simone pulls him aside. “You have the latest 12 lead?”
“Yes, I was going to place it in the chart.”
“Excellent, let’s do that and compare it to yesterday.”
Both go to the nursing station where Simone pulls up yesterday’s 12 lead and looks back and forth from today’s ECG to yesterdays.
“Do you see any differences Denis?”
“Nope, although it is quite a bit slower than yesterday’s. Did you start her on something?”
“Yes, we started her on a beta blocker to slow her rate down and to prevent any remodeling.”
“Well, it seems to be working. Heart rate is about 65, but other than that everything looks the same as yesterday.”
“Ok. Thanks Denis. See you tomorrow?”
“Yes, I’ll be here about the same time.” Denis then grabs his ECG cart and heads down the hallway to another patient.
Time: 14h00
“Good afternoon, Mrs. Smith.”
“Hello.”
Dorothy looks up to see a slightly stooped women enter the room and pull a chair up to the bedside. “Who are you?” she asks.
“My name is Stella and I am a social worker for the hospital. I come and see all the cardiac patients to make sure things are going well and to see if I can help at all.”
“Oh, not sure what you can offer.”
“Me neither, but lets have a conversation. Then I might have something a bit more definitive.”
Dorothy looks Stella over a bit more. “I guess that’s ok. Meryl has psych coverage as part of the RCMP so not sure what you can help with?”
“That’s good to know. If there’s something that needs to be shared, I can share it with the RCMP. It benefits people to ensure there is good coverage. I have a few set questions to ask, but please feel free to interrupt at any time. I do this to see if there are any gaps and where a social worker can assist you in your new journey to better health.”
Both Meryl and Dorothy nod.
“Ok, how long have you two been together?”
“We have been living together four years, but have dated for about eight years before moving in. I met Dorothy while I was having a coffee break and stretching my legs after being in the patrol car for 10 hours on a stake out. She was sitting in a booth by herself and the restaurant was completely jammed. I asked if she wouldn’t mind sharing her booth and she told me that it was ok and that I looked to be a safe person. We started talking and here we are 10 years later. She was the right person at the right time after my previous relationship dissolved due to him cheating with the teaching assistant.”
“You were previously married?”
“Yes, before Dorothy, I had a traditional family with a male husband. We were together for about six years. I never really felt comfortable in the relationship, but thought that that was what a woman should be when being a wife to a male. Anyway, he started cheating after I had our second child and then I just left.”
“How many kids?”
“Two. A boy, Roger, and a girl Jennie. Very lovely kids, but they’re growing up so quick. Roger is 16 and Jennie is 14. We share custody. Although Matt, my ex-husband, gets weird with me living with Dorothy.”
“Any issues with the coparenting or the kids?”
“No, the kids have adjusted nicely to having two moms and have really bonded with Dorothy.”
“How long have you been with the RCMP?”
“Twenty-four years—looking at retirement in about five or six, I think. Got a promotion three years ago that took me out of the patrol car and more desk duty. Been a little less active since that time, riding a desk.”
“Yes, physical activity is important. I think that is Addy’s day two talk after she gives you the news about your diet.”
All three women laugh.
“Oh, I am still active, just not the same level as when I was in a car. I like to walk, run a little, and really enjoy hiking on some of the trails we have around here when the weather is nice.”
“Sounds lovely. Good way to relieve stress in your type of job.”
“Yes, I guess so.”
“Do you smoke?”
Both women shake their heads no. “We both quit years ago. Never felt the need to take it up again.”
“How about alcohol?”
“Dorothy and I enjoy a glass of wine after work and the occasional martini when we go out, but I don’t think it’s excessive. What do you think, Dot?
Dorothy ponders this and a few seconds later answers. “Not sure we do drink every day, but only a glass, so I don’t feel it’s excessive.”
“Sounds quite normal to me. Ok, thank you for answering my questions. You are very normal people and look like you have the coping skills and support needed to make the adjustment that heart failure requires. I don’t think I need to be involved. With your permission, I would like to send a note to your HR benefits person in the RCMP to give them an update, and maybe they can follow up with any necessary assistance. “
“That would be fine.” Meryl then gives Stella her division number and the contact information for benefits in her division.
“Thank you both. Have a great day.”
Stella heads out of the room and to the nursing station to update her notes.
Simone comes by just as Stella is finishing up. “Anything I need to know?”
Stella looks up and smiles. “No, I think she is doing pretty good. I don’t believe the diagnosis has really hit her or her partner yet. Right now they’re still processing. On the plus side, good supportive family, and she has great support from the RCMP so things are setup well for her to be successful in this transition. The real question is: will she be allowed to continue to work or will the RCMP push for retirement? But that’s not my decision and could add quite a bit of stress to Meryl and Dorothy.”
“Thanks Stella. I have a good feeling about them. Will you check in with them again?”
“No. I’ll see them in the healthy heart clinic, but I don’t think I need to follow up beyond that.”
Simone nods and moves over to complete her charting on the other patients she is caring for.
Time: 16h00
“Hello Mrs. Smith, how are you doing?” Simone asks as she looks over the monitor and does a primary sweep of her patient.
Meryl looks up with reddened eyes, “It’s going ok I guess.”
“Have you been crying, Mrs. Smith?”
“Just a little. I just. Why me?”
“I don’t know why this has happened to you, but I can explain things a bit more to you if you would like?”
“That might help. I think it’s suddenly hitting me that my body is changing and not for the better and I may have to retire and make so many changes. I, oh gawd. I just don’t know what to do.”
“This is perfectly normal. Let me pull up a chair and I can explain what is happening in your heart ,and what the plan is for you. Does that sound ok?”
“Yes, thank you.”
Simone sits down beside Meryl’s bed and explains how heart failure develops when a valve is not working, how valves become diseased, and the various treatments. She also carefully discusses some of the complications that can develop if Meryl does not follow doctor’s orders.
“Oh, thank you. I think I understand a bit better now. It looks like I’m not going to die.”
“Yes, Mrs. Smith, with the correct treatment, and you watching your diet and exercise you can live a very enjoyable life—maybe not the one you envisioned, but still quite enjoyable.”
“Yes, I think it’s all the changes I am facing that is overwhelming me. “
“Could very well be. Often facing one’s mortality can be a bit daunting. You need to give yourself time to grieve and recognize that this has happened to you and that it is not a punishment, but something that you need to deal with. Remember, there are many people here to help you and Dorothy make the best of this situation and diagnosis. You need to allow us to help you.”
“Thank you again. Yes, I will be asking for help now. What is the plan for tomorrow?”
“Much the same as today. You will have another chest X-ray, ECG, and lab work. I hope that I’ll be able to take you off oxygen, and then, if that happens we can introduce you to the heart failure clinic, which will begin an exercise routine with you to help strengthen your heart and your coping skills.”
“It would be nice to begin moving around again.”
“Let’s plan to do that tomorrow, shall we? I can hear the dinner trays being moved about in the hallway, so I’m going to get your meds and check on my other patients.”
Meryl smiles and pats Simone’s hand.
Simone moves the chair back to the corner and heads off to gather meds and check her other patients.
Day 2: Medical Ward
Day: 2
Time: 08h00
Place: Medical Ward
Simone looks over the MAR and double checks the meds she is pulling for Meryl Smith. That all looks right, she thinks to herself. Beta blocker, ACE-I, and Lasix. Along with some vitamins and a proton pump inhibitor. Let’s go see how she is doing this morning.
Walking into the room, Simone can immediately see that things are not right. Looking up at the monitor she sees that Meryl’s heart rate is 50 and that she looks a bit pale.
“Good morning, Mrs. Smith. How are you doing?”
“I don’t feel quite right. I am not sure what is going on?”
“Ok, I am going to listen to your chest and take your blood pressure.”
Simone carefully listens to Meryl’s chest and hears a few less crackles than yesterday. Nodding to herself she thinks, A bit better but let’s check the BP.
Pressing the NIBP button on the monitor, Simone waits a few seconds and sees the result displayed on the screen: 84/48. Placing her forefinger on Meryl’s wrist, Simone double checks that the pulse is accurate when compared to the monitor.
| Day: 2 | Pulse Rate | Blood Pressure | Respiratory Rate | Temperature | O2 Saturation |
| Time: 08h00 | 50 | 84/48 | 18 | 36.5°C | 95% on 3lpm |
“Well, your heart rate is a bit slower than it was yesterday and your BP is a bit lower. All this can be caused by your medications, so before I give out your meds, I’m going to have Dr. Grant take a look.”
“Sure sure.” Meryl leans back against her pillow and closes her eyes.
Hmmm, a bit tired as well. Ok let’s find Dr. Grant, thinks Simone.
Simone steps out of the room and sees Dr. Grant at the nurses’ station.
“Dr. Grant, before you start rounds, can you quickly see Meryl Smith? Her heart rate is 50, BP 84/48, and she is a bit drowsy.”
“Good morning, Simone. That sounds like she is having some issues with her meds. You know me by now: if they can keep their eyes open, I’m ok with whatever BP they have.”
“True enough, but it’s more the heart rate that is concerning me and her drowsiness.”
“Ok, let’s do a quick drive by and see how things are going.”
Dr. Grant and Simone head to Meryl’s room. They find her propped up in bed staring forlornly at her breakfast tray.
“Hello Mrs. Smith. How are you doing?” asks the doctor.
“Would be better with some sausages and pancakes, not the cardboard and watery milk that you’re feeding me here.”
“Ok. Do you mind if I have a listen to your chest and check you out before you dig into breakfast?”
Meryl pushes the bedside table away and adjusts her gown for Dr. Grant to listen to her heart and lungs.
After Dr. Grant finishes checking Meryl out, he steps back. “Ok, Simone, I am good with the BP, as that is not affecting her too much, so the ACE-I is good. She is down another ¾ of a kilo in weight. The heart rate is down a bit more than I would like. Let’s cut her dose of beta blockers in half and then go a bit more slowly up than we have been. Give her body a bit more time to adjust to the new drugs. How does that sound?”
“Great, thank you. Will you write that out as an order?”
“Yes. In the meantime cut the beta blocker pill in half. She needs to get on these drugs to get better.”
“I will do that and give her the half dose with breakfast along with the rest of the meds. Thanks again.”
Both professionals leave Meryl alone with her breakfast tray.
A few minutes later Simone comes in with the medications and explains everything to Meryl and the reason behind the changes. Meryl seems to understand but is still unhappy about her breakfast.
Time: 19h30
Dorothy peeks around the corner. “Up for a visitor?”
“Oh yes. Someone not dressed in those awful blue pajamas and who will talk to me about something other than my heart. What is that I smell, french fries?”
“Shhh the pajama police will hear!”
Both women share a laugh.
“You shouldn’t. It’s not on my diet!”
“You are doing so well, I thought we could celebrate. I brought a milkshake as well. I looked up on the web to see who had the healthiest French fries and I went there to pick some up to share.”
“Healthy fries? You are looking out for me, eh, or trying to get my life insurance payout?”
“Nothing of the sort. Just celebrating.”
The two women sit close and share what happened over the course of the day. For Meryl, it was a normal hospital day with another ECG, chest X-ray, and lab work. But she did share that she was able to go for a walk with the physio, up and down the hallway. Dorothy shared about the kids’ parent teacher interview and laughed at how awkward her ex-husband felt when he had to explain that Dorothy was not his wife but his wife’s wife.
An hour later with visiting hours almost over, Dorothy cleans up the evidence of the celebration, kisses Meryl, and waves good bye. “Till tomorrow hon.”
Time: 22h30
“Hello Mrs. Smith. Let’s get you tucked in and taking your final meds of the evening.”
“Ok Siri. Has Dr. Grant changed any meds again?”
“No, everything is the same as it was this morning. We are going a bit lighter on the beta blockers and allowing you to adjust a bit slower to them.”
Siri then helps Meryl to the bedside commode and gives her the PM medications. Checking again with her that everything is fine, she turns the lights off in the room, leaving each patient with control of their own bedside lighting.
Day 3: Medical Ward
Day: 3
Time: 03h00
Place: Medical Ward
Meryl wakes up suddenly. Something’s not right, she thinks to herself. Oh my heart is beating so quick. I can’t catch my breath. What the hell is going on? Where is that damn call bell? Looking around her bedside in the dark, she finds the call bell and pushes it. A few minutes later she sees a flashlight waving around on the floor as it approaches her bedside.
Siri peeks around the corner of the curtain to find Mrs. Smith sitting upright in bed breathing rapidly and looking quite panicked.
“Well, Mrs. Smith, things don’t look right. How are you feeling?”
“I don’t feel good at all. Not sure why. I feel short of breath and I feel like my heart is just pounding.”
“Ok, let me turn the lights on here and give you a good once over.”
Siri turns the lights on over the bed, considers the monitor, and sees Meryl’s heart rate at 100. Saturations are less than 88% on room air. Something isn’t right, she says to herself. I wonder what’s going on?
“I’m going to take your blood pressure and listen to your heart and lungs.”
Siri listens to Meryl’s chest and hears substantially more crackles than at the beginning of the night shift. The BP cuff beeps and the monitor shows 90/50.
| Day: 3 | Pulse Rate | Blood Pressure | Respiratory Rate | Temperature | O2 Saturation |
| Time: 03h00 | 100 | 90/50 | 24 | 36.5° C | 88% RA |
“Ok, something is not quite right Mrs. Smith. Let’s put you on a bit of oxygen. I’m going to ask the RT to see you, along with Dennis the senior resident. I expect we are going to do a chest X-ray and another ECG and some labs to see what’s going on.”
“If you say so. Oh, why is this happening?”
Siri grabs the nasal prongs hanging on the flowmeter and places them on Meryl’s nose. She turns the flowmeter on to 3 LPM. Not waiting to see what happens, Siri rushes out to the nursing station.
“Can you page the RT for me and find Dennis? I’d like both of them to see Meryl Smith in Room 23.”
“Dennis is just seeing the patient that came in last night at 22:00. I think he’s almost done, but I will let him know you need him. Jackson is the RT covering the floors and I’ll page him now.”
“Thanks.”
Time: 03h20
“Hi, I’m Jackson the RT. You paged?”
Siri turns to see a very tall, smiling male dressed in bright blue scrubs. “Yes we did. Wow, are those the new RT scrubs?”
“Yeah, a bit bright, eh? They tell us they will fade with washing. Same colour as my grad suit was during the high school prom. Not a great colour then and less so today.”
Siri laughs. “Ok. Mrs. Meryl Smith is a 44 year old woman who developed heart failure due to a heart murmur that occurred 16 years ago during her last pregnancy. She was doing fine and came off oxygen 24 hours ago. Just a few minutes ago, she rang and complained of distress and shortness of breath, and her sats were down. I put her on 3 LPM nasal prongs and have not had a chance to double check to see if that worked.”
“Ok. Well, let’s look now.”
| Day: 3 | Pulse Rate | Blood Pressure | Respiratory Rate | Temperature | O2 Saturation |
| Time: 03h20 | 102 | 92/55 | 26 | 36.5° C | 90% 3 LPM |
Both Jackson and Siri head into Meryl’s room to find not much of a change with saturation around 90% and HR around 100. Latest NIBP is 92/55.
“Hi Mrs. Smith, my name is Jackson and I am a respiratory therapist. I manage oxygen for patients and it seems you might need a bit more. I need to listen to your lungs. Is that ok?”
Meryl just nods.
Jackson listens quickly. “Wow, she is crackly everywhere. I’m going to get a mask and a water bottle. I’m probably going to put her on .5Fi02 and see how she does. Is the doc going to see her?”
“I’ve asked Dennis to come in and review, which I hope is soon.”
Just then Dennis walks in. “How is this for soon?”
Siri smiles “Pretty good. Jackson is going to place her on oxygen. She woke up in distress about 15 minutes ago. HR is up, BP is up, and saturations are down. She is complaining of SOB and not feeling quite right.”
“Ok. Jackson, what did you hear chest-wise?”
“She is crackly in all fields. I’m going to place her on .5 mask and see how she does. Resps are about 26 per minute right now.”
“Thanks, I’ll order a CXR and 12 Lead, with CBC, lytes, BUN, creatinine along with a troponin to see if this is an MI. After I look at the CXR, I may order some Lasix as she may be having an exacerbation of heart failure.”
Siri stays with Meryl while Jackson gets the oxygen mask and Dennis writes the stat orders.
Over the course of the next hour, Meryl’s saturations improve to 93% on .5 Fi02. A chest X-ray is complete, a 12 lead is done, and all morning lab work is completed.
Siri and Dennis are both looking at the CXR and the 12 Lead. “Ok, Siri what do you see on the CXR?” Dennis asks.
“Well, comparing it to yesterday, she seems to have a lot more infiltrates generally. There doesn’t seem to be a pattern nor does she have a temperature or cough so I think, for some reason, she is retaining more fluid or her heart is not pumping very well.”
“Excellent. I agree as well. Let’s look at her 12 lead.”
Both professionals compare the last two days’ 12 leads with the one taken a few minutes ago.
“Same question, Siri. What do you see?”
“Well, comparing all three ECGs, they all look the same. If we are looking for an MI, I don’t see any ST elevation nor Q waves on tonight’s ECG. She could be having a NSTEMI I guess.”
“That could be happening, but I’m suspecting it’s something else. I wonder if the trop is back yet.”
Dennis pulls up the computer and looks under Meryl Smith’s lab work. “Awesome. Look here: no troponin detected. So, no MI. Let’s give her 40 mg IV Lasix now and if she responds really well, just follow up with her normal AM dose. If she has a limited response, say less than 1500 cc urine in the next three hours, let’s double the dose. But talk to me first before doing so. I’ll write the order for the 40 mg direct IV.”
“Ok, something happened here. I’ll go see how she’s doing and talk with her.”
Time: 04h30
“How are you feeling now Mrs. Smith? I am going to give you some Lasix that will make you want to pee quite a bit for the next little while.”
“Ok, is the commode close?”
“Yes it is, but I want you to call if you need to get up. Just want to make sure nothing happens or you slip. Ok, here goes the medication. Has to go in quite slowly.”
Siri very slowly pushes the 40 mg IV over the next 5 minutes into Meryl’s IV.
“So all those tests we did show you did not have a heart attack, but show that your heart is not pumping as well as it was yesterday. Anything different happen?”
Meryl sighs and looks sheepishly at Siri. “Dorothy and I celebrated just a little after dinner before you came on shift.”
“What do you mean?”
“Well, Dorothy brought me fries and a large milkshake, you know one of the big ones.”
“Oh my. Ok, I think I know what happened. Addy talked to you about salt and water, did she not?”
“Yes. I am not supposed to have too much of either.”
“Yes, no extra salt and we’re watching your fluids very carefully. So the extra salt from the fries caused your body to hold onto fluid, then the extra big milkshake gave you more fluid than your heart could handle, causing your heart to be overstretched and not pump well. The Lasix that I’m giving you will help, but you can’t do things like this.”
“Yes, I know that now. Thank you. Are you going to talk with Dorothy?”
“Not tonight. But I think you both need to meet with Addy and Stella.”
“Ok.”
Time: 06h30
Siri helps Meryl back to bed for the eighth time since the Lasix has been given.
“Oh, I feel so thirsty.”
“Yes, here is some water. Just take a sip and rinse it around your mouth before swallowing. That will help with some of the dryness.” Siri removes the pan from the commode and measures the urine. That gives us a total of 2200 cc since 0430. Not bad, she says to herself.
“Ok, about two liters out. How are you feeling?” Siri checks the monitor and sees the heart rate below 90 and saturations sitting at 99% on the .5 Fi02.
| Day: 4 | Pulse Rate | Blood Pressure | Respiratory Rate | Temperature | O2 Saturation |
| Time: 06h30 | 88 | 110/75 | 20 | 36.5° C | 99% .5 FIO2 |
“Much better,” Meryl says. “Feels like I’m back to where I was yesterday.”
A few minutes later Jackson comes in to check on Meryl.
“How you doing now? Wow — 99%. Let’s see if we can get you off the mask and onto something more comfortable or maybe even off oxygen.” Jackson removes the mask and replaces it with nasal prongs at 3 LPM.
“I’ll be back in 10 minutes to see how you are doing.”
Time: 06h45
“Ok, Mrs. Smith, your sats are 96% on 3 LPM. Let’s take you off the oxygen. I’ll ask my day shift counterpart to check on you when they come in, but I think you don’t need the oxygen anymore now that you got rid of all that fluid.”
“Thank you. I feel so guilty. I did this to myself and I thought I knew better.”
“Hey, now you know. Have a good morning Mrs. Smith.”
Time: 07h30
“Hi Simone, back again?”
“Yeah, Philippa wanted to trade her day shift for a night. Something to do with a school outing, I think.”
“Very happy to see you. Should be an easy report.”
“Thanks Siri.”
“Ok, everyone had a good night except Meryl Smith, but will get to her in a minute. Beds 2 to 6 are ready for discharge as soon as the morning labs are back. Discharge orders are written. If labs are normal, they are good to go. I have phoned all the family and they are aware to come and pick them up. I have updated my charting and everything should be a go for them.”
“Thank you very much. Now what happened with Meryl?” Simone asks.
“The evening started out well. HS meds and care, she was doing fine. Did not need any assistance to commode. Then at 03:00 she wakes up not feeling right, SOB, sats down, chest sounding quite crackly throughout, and did not look exactly right. RT up, placed on FM at .5 Fi02, stat blood work, CXR, and the resident in to see her. Appeared to be having either an MI or acute exacerbation of HF. Labs came back with trop negative, 12 lead unchanged but CXR showed increased infiltrates. Had a bit of a discussion with her and it seems her and her partner celebrated how well she was doing with fries and an extra large milkshake. Looks like this tipped her over the edge. She received 40 mg IV Lasix. Diuresis of 1.5 L out and this morning is off oxygen with sats of about 93%. She feels pretty guilty. I think social work and Addy from dietary need to come and talk with both her and Dorothy to do some teaching.”
“I agree,” nods Simone. “When they were talking yesterday the conversation seemed a bit too easy. More teaching is definitely needed.”
“Ok, Simone, that’s it for me. This is my last night shift so maybe see you next week. Have a great shift.”
“Thanks Siri, I hope you get some sleep.”
Time: 08h10
The discharge patients are all up and dressed, Simone says to herself. Breakfast trays delivered. So they should be good. Right. Let’s go see Meryl and see how she is doing.
Simone double checks that she has the right meds, remembering yesterday that the beta blocker was adjusted.
Entering the room, she finds Meryl sitting up in bed looking much better than yesterday morning, despite the events of the night shift.
“How are you feeling Mrs Smith?”
“Much better thank you. I imagine you know what happened last night.”
“Yes I do. How do you feel about that?”
“Very embarrassed and a little scared.”
“I can believe that. Here are your meds for the morning. It looks like your heart rate is good at 65. Let’s do your blood pressure and then afterwards let’s talk about last night.”
“Ok. You aren’t mad, right?” says Meryl.
“Definitely not. I just want to help you develop a better understanding of your disease and see what we can put in place to prevent these sorts of things happening again.”
“Thank you.”
Over the course of the morning, Meryl discusses her feelings with Simone and seems to show a deeper understanding of heart failure and the implications. When Dorothy comes in, Addy and Stella meet with the two women and provide counseling and coping strategies.
The next three days show great improvement with Meryl. On the fourth day, she is discharged home, with appointments for follow up to the health heart clinic.