Case study
Joe, a 43-year-old man with a history of hypertension, arrived at the emergency department (ED) with right upper quadrant pain. His blood pressure was 155/85 mm Hg, and his heart rate was 110 beats per minute (bpm). On examination, his right upper quadrant pain was confirmed with difficulty because of his morbid obesity. The ED physician ordered routine laboratory tests and an ultrasound of the right upper quadrant to confirm cholecystitis. The client complained of increasing pain and required several doses of intravenous (IV) morphine to control his pain. This examination, blood work and the ultrasound, took about 7 hours. The ultrasound showed some sludge in the gallbladder but no stones. Over this period, Joe’s heart rate and blood pressure both increased to 120 bpm and 175/95 mm Hg, respectively. The blood work results were all in normal range except his creatinine, which was increased from the baseline of 1.1 to 1.8 mg/dL indicating acute kidney injury.
The ED physician ordered a computed tomography (CT) scan of the abdomen without contrast because of the acute kidney injury. The CT scan was delayed by about 4 hours for logistical reasons, and it took about an hour for the initial reading to be returned to the ED.
QUESTIONS:
1. What was the cause of the abdominal pain?
2. Why do you think the blood pressure and heart rate keep increasing?
3. What client complaints would you expect with this scenario?
4. What are the potential liability issues?
Part 2
Remember Joe, the man in the ED with suspected cholecystitis? He waited 7 hours for initial screening and another 5 hours to get the CT scan and the results read. A diagnosis of possible aortic dissection was returned, but the results were unclear. After a consult with several other physicians, a CT of the lower abdomen and pelvis was ordered, and a dissection of the descending aorta was diagnosed.
The Rest of the Story
After another 90 minutes, a second CT scan was ordered and a dissection of the proximal aorta with involvement of the carotids and descending aorta (a type A dissection) was shown. The client was give aggressive intravenous antihypertensives and taken immediately to the operating room for repair. Unfortunately, he suffered a massive intraoperative bleed during the complicated surgery. He suffered multiple organ failure and hemorrhagic shock. He died 2 days later after maximal intervention and effort.
https://psnet.ahrq.gov/webmm/case/407/diagnostic-d…
QUESTIONS:
1. Review the case: note how long Joe waited for initial screening and how much longer did he wait for the initial CT scan? After receiving the diagnosis of a dissected aneurysm, how long did he wait for the second CT scan. What is the total of his wait time?
2. Do you think that the wait time is reasonable? Why or why not?
3. Do you think the wait time contributed to Joe’s death? Why or why not?
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