I was so glad 3 o’clock finally came and I was giving report to the evening charge nurse. It had been a long but good day in the ED. Just as we were wrapping up report, the dreaded EMS radio went off. I answered and Needham Fire came on line. “We are bringing in an 88 year old male patient complaining of chest pain, alert, with stable vital signs. IV started and 324 aspirin given. We are at your back door; just coming from across the street.” That last statement was the key. The evening charge nurse and I looked at each other and said, “gotta be Mr. P”. I know we both had the same thought: “How many times has he been here for this chest pain?” And lo and behold there was Mr. P on the stretcher.

I stayed to help get Mr. P triaged; this was fairly quick for me since I had taken care of him so many times. Mr. P stated that he awoke this a.m. with chest pain and it just had not gone away. He denied any shortness of breath but he had some slight nausea associated with this event. Of course most of Mr. P’s history is known to the ED staff but just in case, Mr. P keeps his cherished index cards, which documents his history, in his upper shirt pocket. Mr. P does have some short term memory loss but he never forgets his index cards! He also has a history of coronary artery disease and hypertension which has been worked up in the past and has been managed with medications. I stayed just long enough to get him tucked in and off I went as I was done for the day.

At 0700 the next morning, Mr. P was still on the “dash”. He had been admitted to our OBS unit over night. The night shift informed me that Mr. P ruled out, as both sets of troponins and both EKGs were within his normal limits. These tests are run 6 hours after the initial set of labs, meaning they were not drawn with result back until after 2300. The night ED team decided to admit him to the OBS unit instead of sending him home so late knowing that he lived alone. The plan from report was to discharge him this morning. I assigned myself to be Mr. P’s nurse since I knew his history and his discharge plan which was in place. I was also in charge for the day. The day shift MD, Dr. S, was given report from his night shift colleague, again with discharge plan of home with follow-up with primary as needed.

I started my day by first assessing my other patient, and then headed down to Mr. P’s room. The room was dim and Mr. P was awake, but he did not acknowledge me when I went in. I asked Mr. P how he slept and he said “OK” but still he did not feel well. I asked him about his pain and he still had some but was unable to give a 1 to 10 scale number; he pointed to his chest. Upon my assessment, he was pale and warm to touch. Temperature was low-grade 100.4, he was in a sinus rhythm with regular respirations and lungs were clear upon auscultation. Blood pressure was also within normal limits. When I assessed his abdomen, he was slightly tender with positive bowel sounds and he continued to complain of slight nausea. I knew something was off. Mr. P. was not Mr. P. There seemed to me to be a slight change in his mental awareness. He surely did not have his Mr. P smile and he was just “not right”. So many thoughts were running through my head, “why does he have this low grade temp”, “why when I pressed on his abdomen did he grimace ever so slightly?” Mr. P had not complained of any abdominal pain - only his chest pain. I had an uneasy feeling that we were missing something.

As Dr. S was getting ready to print the discharge instructions for Mr. P, I updated him on Mr. P’s condition. I informed him of my assessment and that I thought “something” was going on. What was I missing? The attending said a low grade temp was not of concern and it was ok to send him home with this as all of his other vital signs were within normal limits and his cardiac work-up was negative. Dr. S said Mr. P did not voice any complaints to him and he looked “ok”. He then went on to say that Mr. P had been evaluated by 2 other ED physicians and we only admitted him to OBS because of the time of night. It would have been very easy for me to go along with the discharge plan. He did have a negative work-up and, yes, he could have been sent home last night but he wasn’t. I knew I could not let Mr. P be discharged. I went on to say that I had taken care of Mr. P so many times and I knew him well and he was not himself. I felt that a hospital admission was needed. I was not going to let this go. It is a testament to my practice and professionalism that Dr. S quickly responded to my concerns regarding Mr. P. Without hesitation Dr. S went and re-assessed Mr. P. Upon his reassessment Dr. S. also noticed that Mr. P. grimaced when he palpated his abdomen and Mr. P verbalized that his “stomach hurt”. Not sure what was causing this pain Dr. S called the hospitalist to arrange for Mr. P’s admission.

Mr. P was admitted to the floor and within 24 hours he was transferred to the ICU as his condition deteriorated. As I continued to follow Mr. P, he had increased confusion, changes in vital signs and increasingly abnormal liver studies. He was diagnosed with cholangitis. Antibiotics were started and he was transferred to BIDMC within 48 hours of arriving to the ED with what we thought was Mr. P’s usual chest pain. Mr. P underwent an ERCP with a sphincterotomy and a biliary stent was placed for a small intra-hepatic bile abscess. Mr. P’s post procedure hospitalization was uneventful and he was discharged home 3 days later.

I chose this story for several reasons. I made a difference in Mr. Ps’ care. I trusted my gut and persisted in articulating my concerns. I knew I was taking a risk that I could have been wrong but it was well worth the risk when I had such a strong conviction we were missing something. I was willing to have Mr. P admitted and have a negative work-up than for him to be discharged and return critically ill. This incident with Mr. P. taught me a great lesson that I now incorporate into my nursing practice. Each and every patient visit must be treated uniquely. Knowledge of the patient’s past medical history is important, but it is equally important to maintain your objectivity and to make no assumptions. As well as I may know a patient, I must always be cautious not to draw a conclusion too soon. The joy of working in a community hospital is that we get to know our patients extremely well. This special knowledge base allows me to recognize subtle changes in my patients that otherwise might be missed.

My experience with Mr. P reinforced my core belief that I always need to be my patient’s advocate. I realized Mr. P was unable to express his concerns or fear about his discharge. He was also unable to communicate his pain and change of condition. I needed to be his voice. As a profession we must speak up and communicate our assessments effectively, including changes in our patient’s condition and evaluation of our patient’s needs. I have the great pleasure and privilege of continuing to care for Mr. P. FYI, I am happy to report that his index cards have now been updated!