Hospital acquired pneumonia - possible timeline?

Los Pollos Hermanos

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Good whatever time of day it is where you are!

Is there a US-based doctor or nurse in the house?!

If anyone is unfortunate enough to have person experience and is willing to share anything they're comfortable with, I'd also really appreciate it. Please don't feel obliged though, as I really don't want to upset anyone.


The trilogy has gone off for proofreading (a brutal friend who has her own business), although I have warned her I might want to tweak part of a flashback in Book 3. There's a few flashbacks from Mr Good Guy in Book 3 as the net closes on Mr Bad Guy.

Bear with me as I set the scene.

Mr Good Guy ended up in hospital in Book 1 after a Very Nasty Car not-so-Accident. I'm confident on the medical details, having run them past a doctor (he's a consultant anaesthetist) friend of the family. Part of a conversation (slightly paraphrased):

Him: How long do you want him in hospital for?
Me: A month.
Him: These injuries would keep him in about two and a half weeks.
Me: Has to be a month. I don't want to make the injuries worse, as too much melodrama is a big no-no.
Him: Give him hospital acquired pneumonia. With the types of injuries he sustained and his subsequent treatment he'd be a prime candidate. That'll keep him in an extra couple of weeks on IV antibiotics for a week and then oral antibiotics for another week (he then went on the give me lots of useful info about treatment, etc.).

So... I've got the details of what, how, etc. He ends up in a High Dependency Unit (Step Down Unit as I believe they're called in the US) for five days and on non-invasive ventilation for three of those days. I needed a setback, shall we say, to affect his physical and psychological recovery from the not-so-accident.

In Book 1 the pneumonia is only mentioned in passing. The Book 3 flashback centres on him developing symptoms and being admitted to the SDU. The rest is covered in a paragraph. The reason I'm asking on here is because things might be done (slightly) differently in the US and my doctor contact is 100% Limey. I realise every case is different, but a plausible timeline would be marvellous.

Current scenario is that when patient wakes at breakfast time (so say ~8am) he's running a slight fever, feels iffy, bit of a cough and declines anything to eat or drink. Nurse is concerned, gets doctor. Doctor is concerned. (Patient was feeling off colour for most of the day before but deliberately didn't mention it as he's desperate to go home asap). Mrs Good Guy is phoned and arrives an hour or so later after dropping off their daughter with a friend.

In no particular order I'm after how long(ish) it would take to:
* Run tests to establish that he's likely got pneumonia - listening to chest, X-rays, blood tests, anything else?
* Put him on extra oxygen, IV antibiotics, any other new medication.
* How he might be presenting to the medical team**.
* His symptoms to get bad enough to move him from the Medical-Surgical Unit to the SDU.
* Anything else relevant.

** I've used websites like:
http://www.lung.org/lung-health-and...ookup/pneumonia/symptoms-causes-and-risk.html
for the facts, although we all know it's those authentic little details that can make or break a scene.

Like I said before, I know all cases are different, but a realistic timeline of how the illness progresses to the point of bring transferred (and at what point tests are done and treatment(s) started) would be really helpful. I don't need nitty gritty details - because he'd be out of it for much of the time he wouldn't remember nitty gritty details, even if I wanted him to.

I think/hope that makes vague sense?

Many thanks in anticipation,

LPH.
 

Lauram6123

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Okay. This is coming from an American Radiologist...

Because your guy would originally (before pneumonia) be on a trauma / surgical service, 8am is a little late because surgeons round very early; more like 6am or 7am at the latest. They discover the fever from the vital signs on the nursing report (unless he/she notifies them before rounds - possible if the fever is very high.) That would prompt a physical exam of the lungs during rounds, when abnormal breath sounds would be detected. This would prompt them to order a chest x-ray, and maybe some labs such as white cell count etc. The chest x-ray would be done and reported within a couple of hours. There's probably an intern on the trauma team who is following up from all the morning rounds stuff, and he/she would inform the chief resident or attending doc by about 10am. At the least, they would then order some IV antibiotics. If they decided he was sick enough to go to step down, they would initiate the transfer process. If you want him to go to Step Down, then you might want to make him a little sicker, because often pneumonia alone isn't enough. Maybe make his blood pressure and or urine output low also. The transfer process can take a while, perhaps several hours given the paper work, availability of beds, transport, exchange of nursing reports, etc. I think 4 or 5 in the afternoon is fairly optimistic.

Hope this helps.
 

Los Pollos Hermanos

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Many thanks for the info - it's a massive help. :)

He was actually transferred to a hospital closer to home three days earlier and "Dr Andy" (my UK-based source) suggested this was enough time for microbes in his new environment to start the pulmonary party. He's recovering from a cerebral contusion and fractured skull, fractured ribs and associated collapsed lung, liver contusion, torn spleen (small tear so repaired and left in situ with close monitoring) and a compound fracture of the radius and ulna AND a displaced closed fracture of the ankle (I also needed the poor bloke to have reduced mobility for a few months). Would that be enough for them to think "Ooooh heck, better get him to the SDU sharpish"? (my characters don't talk like that, btw).

Now for a little think...

If the surgeon does their rounds at 6.30am what time-ish would the nurse have done their observations for the report?

Would the x-ray be done by one of those portable machines, or would he be taken to the radiology department (that's what they're called in the UK - is it different in the US?)?

How long would it take for the white cell count results to come back?

How quickly would they give him extra oxygen?

If he's showing noticeable symptoms by 6.30am -- cough, fever, lack of appetite -- would it be realistic that by late morning his fever is comfortably into triple digits, he's coughing a lot more and is finding it more of an effort to breathe?

Erm... that's all I can think of for now.

Again, big huge thanks to you!
 
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Lauram6123

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Many thanks for the info - it's a massive help. :)

He was actually transferred to a hospital closer to home three days earlier and "Dr Andy" (my UK-based source) suggested this was enough time for microbes in his new environment to start the pulmonary party. He's recovering from a cerebral contusion and fractured skull, fractured ribs and associated collapsed lung, liver contusion, torn spleen (small tear so repaired and left in situ with close monitoring) (splenic injuries are virtually never repaired....a small laceration that is not actively bleeding will be left to heal primarily, and followed with CT scan....more serious ruptured or bleeding spleens are either embolized through an arterial catheter or simply removed....no one really sews on a spleen) and a compound fracture of the radius and ulna AND a displaced closed fracture of the ankle (I also needed the poor bloke to have reduced mobility for a few months). Would that be enough for them to think "Ooooh heck, better get him to the SDU sharpish"? (my characters don't talk like that, btw).

Now for a little think...

If the surgeon does their rounds at 6.30am what time-ish would the nurse have done their observations for the report?

Nursing generally records vital signs every four hours or so, unless they have orders to space the out more so the patient can sleep. At the least, they will make sure to have it done before the docs come around.


Would the x-ray be done by one of those portable machines, or would he be taken to the radiology department (that's what they're called in the UK - is it different in the US?)

Films done in the department are of far superior quality, and therefore always preferable. Given this guy's extensive injuries, they may opt for a portable which is unfortunately much less sensitive and specific for confidently finding the pneumonia (even more so with all the broken ribs etc.)

How long would it take for the white cell count results to come back

In an efficient hospital, an hour at least, likely a few hours longer in real life

How quickly would they give him extra oxygen?

If he's hypoxic, they could get a nasal cannula on him in minutes


If he's showing noticeable symptoms by 6.30am -- cough, fever, lack of appetite -- would it be realistic that by late morning his fever is comfortably into triple digits, he's coughing a lot more and is finding it more of an effort to breathe?

Sure

Erm... that's all I can think of for now.

Again, big huge thanks to you!

Hope this helps!
 

Los Pollos Hermanos

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It most certainly does! Humungous thanks once again as I'm not very confident writing medical stuff. Murdering someone is fine, but not medical stuff! ;)

The spleen thing wasn't explained very well (by me). I need him to keep his spleen for future "use" (yeah, you're better off not asking!) so Dr Andy said have a fairly minor injury that that the surgeon can sort out and leave it in - so he doesn't have the needing to take antibiotics for life and get immunised against various unpleasant things I can't remember off the top of my head. Dr Andy mentioned the embolisation procedure when I grilled him about medical stuff.

I'll have a nurse do their checks at 6am and say he was ok at midnight. He's been having trouble sleeping (nightmares, flashbacks) so when his condition stabilised they tried to leave him alone as much as possible overnight (I checked this).

I'll just mention he had an x-ray - people can interpret it how they see fit.

With one of those clip-on pulse oximeters, what percentage does the saturation have to dip below for the docs to say "Here's some extra oxygen for you, my good chap!"? My googling is inconclusive.
Quite an interesting bit of kit. I bought one the first time I went to Colorado. I'm usually 98-99% here in England, stayed around 98% in Denver but after 1.5 hours at the top of Mt Evans (14,000+ feet) it went to 96%. I didn't feel any different though, apart from more than a couple of hours at anything over 10,000 feet makes me ravenous.

Big thanks, you absolute legend!
 
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Lauram6123

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It most certainly does! Humungous thanks once again as I'm not very confident writing medical stuff. Murdering someone is fine, but not medical stuff! ;)

The spleen thing wasn't explained very well (by me). I need him to keep his spleen for future "use" (yeah, you're better off not asking!) so Dr Andy said have a fairly minor injury that that the surgeon can sort out and leave it in - so he doesn't have the needing to take antibiotics for life and get immunised against various unpleasant things I can't remember off the top of my head. Dr Andy mentioned the embolisation procedure when I grilled him about medical stuff.

I'll have a nurse do their checks at 6am and say he was ok at midnight. He's been having trouble sleeping (nightmares, flashbacks) so when his condition stabilised they tried to leave him alone as much as possible overnight (I checked this).

I'll just mention he had an x-ray - people can interpret it how they see fit.

With one of those clip-on pulse oximeters, what percentage does the saturation have to dip below for the docs to say "Here's some extra oxygen for you, my good chap!"? My googling is inconclusive. This varies from patient to patient, but certainly when it gets below 90 then it's probably time for extra oxygen. (This is out of my area of expertise, though)
Quite an interesting bit of kit. I bought one the first time I went to Colorado. I'm usually 98-99% here in England, stayed around 98% in Denver but after 1.5 hours at the top of Mt Evans (14,000+ feet) it went to 96%. I didn't feel any different though, apart from more than a couple of hours at anything over 10,000 feet makes me ravenous.

Big thanks, you absolute legend!

You are most welcome. Disclaimer. All doctor stuff was written by Mr. Lauram6123. (He's the radiologist, not me.)
 

ColoradoGuy

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I'm an ICU physician and I generally agree with the above. I have a couple of thoughts to add.

Hospital acquired (aka nosocomial) pneumonia covers a very broad category of clinical syndromes. Sometimes it rapidly progresses over hours, sometimes more indolently. In that it is like other kinds of pneumonia. It depends on the microorganism and other things. So you have latitude really to do whatever your story needs. Fever, cough, increasing shortness of breath, increased respiratory rate, and increasing need for oxygen, all coupled with a new infiltrate on chest x-ray are typical.

As pointed out, we usually start oxygen when the saturation by pulse oximeter gets below 90%. We start with nasal cannula oxygen and move on from there as needed (oxygen mask, noninvasive ventilator, invasive mechanical ventilator).

At least in the US we would never leave a patient to sleep all night without vital signs being measured. Routine is every 4 hours, more often as needed.

These days we can get a chest x-ray very quickly. The portable machines we use have the capability to look at the image immediately. It is also instantly sent to the patient's electronic medical record and we can see it on our computers. I never wait for a radiologist to tell me what's there. ICU docs are so used to reading chest x-rays we proceed once we look at it.
 
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Los Pollos Hermanos

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Ooooh! Bonus for two reasons:

1. Proves my point that things are sometimes done a little differently across the Pond.

This is about two weeks after the not-so-accident. Would they be waking him around 2am to do observations, or could they take their readings from the monitor if he's asleep? I assume he'd still be hooked up some sort of monitor, even in a medical-surgical unit?

2. This part of the story is based in Denver! Nothing like a bit of help from a CO-based medical guru. ;)

As a flatlander (I live at 500 feet) one thing I had wondered about was whether the altitude would affect his oxygen saturation under these circumstances? He's not from Colorado originally, but has lived in Golden for the past ten years and can cycle up Lookout Mountain so I'd assume he's acclimatised?
(I was fine walking on the flat in Denver, but when I had to walk up about fifty steps I felt like I'd jogged up them. I also turned into a one margarita lightweight - haha!)

I need him to go from a bit unwell to being transferred within 6-8 hours. Would a SDU or ICU doc visit the medical-surgical unit if there was a chance they might be getting a new patient? The x-ray would be taken whilst he's still there, so would it be the radiologist doing the interpreting?

ALSO:

Something I've wondered, which I might well need for a future story I'm pondering as we cyber-speak:

Blood loss at altitude. If someone got injured - say in Denver - and lost ~30% of their blood volume, would the effects be more noticeable than if they'd lost the same amount at/near sea level? And, would there be a difference between a resident and a visiting flatlander?

Big, big, massive thanks!
 

ColoradoGuy

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Blood loss at altitude. If someone got injured - say in Denver - and lost ~30% of their blood volume, would the effects be more noticeable than if they'd lost the same amount at/near sea level?
I don't think so.

And, would there be a difference between a resident and a visiting flatlander?
Again, I don't think so. I say that because Denver isn't really that high. For example, I live at 7,200 feet. It makes my relatives short of breath with exercise when they visit, but I don't see it affecting your story. Oxygen saturation of hemoglobin (what the thing on your finger measures) is an exponential function. You don't see much clinically significant effect at Denver level (5,000 feet) but the effects increase sharply if you get higher than 10,000 feet or so. This has been shown in multiple studies.

Those of us who live at altitude generally have higher concentrations of hemoglobin. For example, mine is about 7-8% higher than the usual normal. This has been studied also, particularly in really high places where people live like Peru.
 

Los Pollos Hermanos

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Thanks for clearing that up. It doesn't make any difference to the outcomes for the victims (evil cackle), but if it had done I'd have wanted to incorporate it.

I remember learning (in GCSE biology, so aged ~15) about how people who live in the Andes, Himalayas, etc. have more haemoglobin and more red blood cells - we related it to athletes training at high altitudes as a legal way of enhancing their performance.

I really noticed it in Golden (when I did some reccie-ing for the parts of the story set there) when I walked from town (~5,600 feet) to where the patient lives when he's not being ill (~6,100 feet) and I was puffing like a billy goat! A 500 feet brisk climb wouldn't even make me break sweat here.

If I moved to the Denver area (hypothetically, although I wouldn't grumble if I had to!), how long would it take for my haemoglobin to fatten itself up?!

Cheers...
 
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Roxxsmom

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When I first moved to Boulder, I noticed that I got a bit out of breath trotting up stairs for the first couple weeks, but I adjusted quickly. As Coloraodguy said, Denver isn't that high. I was young and fit at the time, which also helped, and I didn't have asthma or another lung disease. I am older, in cruddy shape, and have developed exercise-induced asthma, so I suspect it would take me longer to adapt if I were to move back to Boulder today.

There are short (changes in 2,3-DPG), and longer-term (increases in RBC count and hematocrit) that happen over a few months. There are also different evolutionary adaptations that exist in human populations that have lived at extremely high elevations for many generations. You or I could live in Nepal all our lives, but we still wouldn't be as adapted to the elevation as most Sherpa people are, for instance.
 
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Los Pollos Hermanos

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Thanks for that article. I read somewhere they're trying to find the genes responsible for these adaptations, but can't remember the source. I find stuff like that really interesting.

The first time I went to Colorado I made the pilgrimage to Fairplay (blame my university days South Park obsession!) and got chatting to one of the shopkeepers. She was telling me about how babies up there usually need to be on supplementary oxygen for the first few weeks, although her youngest had needed it for six months. She also said the little kids don't have much stamina for sports until they're closer to their teens. You learn some interesting stuff talking to the locals!

Cheers...
 

Los Pollos Hermanos

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One thing I've just remembered is bumping into an ex-colleague and her family at Las Vegas airport four summers ago. Her eldest son has CF and she was saying that he really struggled at some of the places they visited in California due to the altitude - I think she said Yosemite NP was the worst. Out of interest, would that be an issue in Denver, or do CF sufferers adapt (to an extent)?
 

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I've read that women who live in towns like Leadville have babies with lower birth weights (and in fact, CO has the highest percentage of low birth weight babies in the country). Anecdotally, my own grandmother lived in Silverton when she had my mom and my uncle, and she had a terrible time with her pregnancies (was very sick with hyperemesis gravidarum) and had some miscarriages between the two. I don't know if the elevation was a factor in this or not (or maybe something in the water) or if it was just her genetics. My mom had a lot of nausea when she was pregnant at sea level too, though it wasn't as bad as it had been for my grandma (the family stories about all that throwing up probably influenced my decision to never have kids).

I don't know specifically how well and quickly people with severe respiratory ailments like CF might adapt when they move to a lower-high elevation places like Denver. I'm guessing it might take longer, since they're already struggling with reduced lung function. It might depend on how well their condition is being managed too. But people with CF do live and receive treatment in Colorado, obviously.
 
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ColoradoGuy

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If I moved to the Denver area (hypothetically, although I wouldn't grumble if I had to!), how long would it take for my haemoglobin to fatten itself up?!

Cheers...

Probably 6 months or so, maybe a month or two less. A normal red blood cell lives for about 3 months so it would take about that long for your red blood cell population to increase significantly. Red blood cell synthesis is driven by a hormone made by your kidneys called erythropoietin. It takes a while for that to kick in.
 

ColoradoGuy

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I've read that women who live in towns like Leadville have babies with lower birth weights (and in fact, CO has the highest percentage of low birth weight babies in the country). Anecdotally, my own grandmother lived in Silverton when she had my mom and my uncle, and she had a terrible time with her pregnancies (was very sick with hyperemesis gravidarum) and had some miscarriages between the two. I don't know if the elevation was a factor in this or not (or maybe something in the water) or if it was just her genetics. My mom had a lot of nausea when she was pregnant at sea level too, though it wasn't as bad as it had been for my grandma (the family stories about all that throwing up probably influenced my decision to never have kids).

I don't know specifically how well and quickly people with severe respiratory ailments like CF might adapt when they move to a lower-high elevation places like Denver. I'm guessing it might take longer, since they're already struggling with reduced lung function. It might depend on how well their condition is being managed too. But people with CF do live and receive treatment in Colorado, obviously.

Leadville has been studied a lot by the pediatric cardiologists at Denver Children's Hospital. They don't deliver babies there any more -- Aspen is now the highest hospital that does. After delivery the pressure in a baby's pulmonary artery, the vessel that goes to the lung, drops as part of the transition to extra-uterine life, bringing more blood to the lungs. It takes a few days to a couple of weeks normally. The Leadville babies had considerable delay in this reflex, which is driven by ambient oxygen. And yes, home oxygen companies are a big business in the Rockies. People with severe lung disease have more problems. As I noted above, oxygen saturation is not a linear function, so once you get above 10,000 feet or so the problems increase quickly. Lots of people with lung disease can tolerate Denver but have trouble in places like Cripple Creek or Leadville. I've had more than a few patients who develop altitude sickness at 10,000 feet and then recover quickly when they come down to 5-6,000 feet.
 

Los Pollos Hermanos

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It's interesting stuff. So, if a baby was born in Denver, its pulmonary artery pressure would drop, etc, etc at a rate comparable to sea level-ish and so no extra oxygen would be needed? Does that mean it would then be okay to go above 10,000 feet for a day out in RMNP say? Or would you leave it until the baby was a bit older? I know what I'm trying to say - haha!

The altitude didn't bother me, I have to say. I did notice above about 11,000 feet, even if I was driving, every so often I'd do this massive sigh for apparently no reason - which I assume was a way of getting more oxygen into me? I was definitely breathing more quickly when I was out and about in RMNP, Breckenridge, etc. but made sure I was swigging the water because I read you lose more water vapour because you're breathing faster, and this can exacerbate altitude sickness.

Actually, a quick couple of questions about patient monitoring (my googling has again been inconclusive):

In a Medical-Surgical Unit, would the patient have heart/BP/oximeter monitoring constantly with the readings displayed, or would it all be recorded as and when needed, along with temperature? Would his previous injuries dictate a particular combination of constant/intermittent monitoring? He's now around two weeks post-accident.

What method/location would they use to measure temperature? Ear? Under tongue? Armpit? Where my cat really doesn't appreciate (he growled Very Loudly at the vet!) having his taken?!? He has no facial injuries (the patient, not the cat).

Cheers...
 
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ColoradoGuy

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It's interesting stuff. So, if a baby was born in Denver, its pulmonary artery pressure would drop, etc, etc at a rate comparable to sea level-ish and so no extra oxygen would be needed? Does that mean it would then be okay to go above 10,000 feet for a day out in RMNP say? Or would you leave it until the baby was a bit older? I know what I'm trying to say - haha!

A baby born in Denver does have a slower drop in pulmonary artery pressure than at sea level. You can measure that but it doesn't make much clinical difference in most of them.

Actually, a quick couple of questions about patient monitoring (my googling has again been inconclusive):

In a Medical-Surgical Unit, would the patient have heart/BP/oximeter monitoring constantly with the readings displayed, or would it all be recorded as and when needed, along with temperature? Would his previous injuries dictate a particular combination of constant/intermittent monitoring? He's now around two weeks post-accident.

What method/location would they use to measure temperature? Ear? Under tongue? Armpit? Where my cat really doesn't appreciate (he growled Very Loudly at the vet!) having his taken?!? He has no facial injuries (the patient, not the cat).

Cheers...

In the US at least there are 3 kinds of hospital beds: ICU, regular floor beds, and something in between, often called step-down or intermediate care. Patients in ICUs always have monitoring leads on, patients in step-down/intermediate often do, and patients on regular floors rarely do. Assuming your character is well enough 2 weeks post injury to be out on a regular floor bed, he would have vital signs (temp, pulse, respiratory rate, blood pressure) taken intermittently without a monitor. Where I work temperature is these days most often taken on the forehead with an automated device called a temporal thermometer.
 

Los Pollos Hermanos

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Good stuff and many thanks!

Were those temporal thermometers (just had a little visit to google images) around in 2008, which is when the flashback takes place? If not, what was the thermometer of choice back then?

If the patient was asleep at 6am, would the nurse do some of her observations before waking the patient? Ideally, I'd like her to suspect something's not quite right before he tries to unsuccessfully pretend that he's feeling fine (he's in complete denial about what happened to him and is desperate to go home).

Cheers...
 

ColoradoGuy

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Good stuff and many thanks!

Were those temporal thermometers (just had a little visit to google images) around in 2008, which is when the flashback takes place? If not, what was the thermometer of choice back then?

Yes, they were around

If the patient was asleep at 6am, would the nurse do some of her observations before waking the patient? Ideally, I'd like her to suspect something's not quite right before he tries to unsuccessfully pretend that he's feeling fine (he's in complete denial about what happened to him and is desperate to go home).

Well, the nurse needs to hold his wrist for a manual pulse and wrap a cuff around his arm for a blood pressure. Respirations can be counted on an asleep person.
 

GeorgeK

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Okay. This is coming from an American Radiologist...

Because your guy would originally (before pneumonia) be on a trauma / surgical service, 8am is a little late because surgeons round very early; more like 6am or 7am at the latest. They discover the fever from the vital signs on the nursing report (unless he/she notifies them before rounds - possible if the fever is very high.) That would prompt a physical exam of the lungs during rounds, when abnormal breath sounds would be detected. This would prompt them to order a chest x-ray, and maybe some labs such as white cell count etc. The chest x-ray would be done and reported within a couple of hours. There's probably an intern on the trauma team who is following up from all the morning rounds stuff, and he/she would inform the chief resident or attending doc by about 10am. At the least, they would then order some IV antibiotics. If they decided he was sick enough to go to step down, they would initiate the transfer process. If you want him to go to Step Down, then you might want to make him a little sicker, because often pneumonia alone isn't enough. Maybe make his blood pressure and or urine output low also. The transfer process can take a while, perhaps several hours given the paper work, availability of beds, transport, exchange of nursing reports, etc. I think 4 or 5 in the afternoon is fairly optimistic.

Hope this helps.
As a surgeon I say the surgeons you work with are sleepyheads. I usually started rounding at 04:30 :), otherwise, yes.

To the OP, An anesthetist is a nurse, an anesthesiologist is a doctor. Also although there are Med-Surg units here and there, the preference is to have separate medical and surgical units because combined units greatly increase the risk of wound infections. Generally flowers as gifts are ok on med units and hopefully banned from surgical units, again due to wound infection risk. Flowers grow in the dirt and dirt often has some pretty nasty bacteria and so flowers typically will have some on them.

Pneumonia in a trauma patient is a risk partly from being in a hospital (statistically 20% chance per day of contracting some sort of nosocomial infection while in the hospital) and the main risk is atelectasis (not breathing deeply enough to clear the stuff that's basically always trying to grow in the lungs).

I remember a staff meeting where the administration presented data on expenses. Another surgeon complained about me having respiratory therapy see patients post op to educate them on proper use and technique of incentive spirometry. He announced, "George is wasting resources!" To which I replied, "That depends on how you look at it. How many of my patients have post op pneumonia and how many of yours do?" The administration nurse sheepishly nodded. He didn't say another word.
 
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GeorgeK

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A few things to add

Splenectomy does not mean lifelong antibiotics. All that would do is breed out resistant organisms which we around here like to call Godzillabacter which may or may not respond to Gorillacillin. Splenectomy does necessitate a few vaccines like Pneumococcal and Meningococcal vaccines and one other which escapes me right now. Those above are correct in that the preference is to watch and allow the spleen to heal and if that's not working you don't repair it, you remove it. Embolizing large organs was a thing a couple decades ago but is frought with significant morbidity and so other than a few specific indications has fallen by the wayside.

I actually just got out of the CCU today and not once did anyone check my blood pressure or pulse manually. They relied on the monitors. The nurses did not observe me while I was sleeping as their habit was always to slam the door open when they entered and then typically failed to close the door. The last place that you want to be if you need sleep is a hospital.

Although in my internist's office they use a forehead temperature probe, in the hospital they used an oral thermometer connected to the same monitor that reads the blood pressure. I think that it may automatically chart things that way so the nurse doesn't have to write things down and maybe get numbers transposed. Obviously different places can and will do things differently
 
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GeorgeK

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Not in Commonwealth countries (maybe Canada). We make a distinction between anaesthetists (doctors) and anaesthetic nurses.
The OP said the setting is US, but yeah, ok.