The patient returned home after being discharged around 6pm, but the pain continued to be quite severe. She called 911 about 2 hours, and returned to the ED. The EMS report is shown below. Her vitals were 82bpm, 18 respirations/minute and BP 131/72. Her O2 saturation was 99%, but for some reason 4L O2 was started. She was given 4mg morphine for her pain.
The nurse intake sheet is shown below. It notes the basic situation and that she “left at 1800, didn’t get meds filled”. Her intake pulse rate is 132bpm, respirations 37/minute, temperature 96.5, weight 272lbs, and pulse ox of 100% (unclear if still on 4L oxygen started by EMS or back on room air).
The patient was seen by a different physician on the bounceback visit. The T-sheet is shown below. The chief complaint is listed as nausea/vomiting recurrence, and abdominal pain is also noted. Her increased pain is noted and the fact that she called an ambulance. The operation she had and the date are also mentioned. He notes “CT scan earlier was fine”. The clinical impression is 1) Abdominal pain – post op and 2) Wound infection.
In the doctor’s progress note, he also refers the reader to an add-on sheet. This sheet shows his orders for Dilaudid, as well as giving a dose of her home prescription medications for Bactrim and Percocet. She was given a dose of Zofran that was not mentioned in this note. The plan is to 1) Fill script and 2) NPO x 24hrs, sips of water with meds, and that she “may have small pieces toast!” The add-on is shown below.
The nurse’s medication documentation is shown here:
The patient’s vital signs are shown below. Note the trend in her heart rate. EMS reported a heart rate of 82bpm, it was 132bpm at ED triage, 130bpm when she was roomed, and the last heart rate recorded was up to 142bpm.
The nurses documentation states:
“Pt nauseated, AxOx3, resp increased, awaiting ERP to see. Will monitor”
“Pain improved, ready to go home”
“D/c instructions, IV dc cath intact, pt wheeled out, Husband @ side”
No testing was done in the ED. The patient was discharged again, and returned home.
Continue to the next page to see the bad outcome in this case.