Reference no: EM133292887

Tom Wilson was feeling slightly nervous as he exited the staff lounge and entered the hustle and bustle of County Hospital's ER to begin his first shift as an RN. The first few hours of his shift passed slowly as he mostly checked vital signs and listened to patients describe their aches, pains, coughs and sniffles. He knew that the attending physician, Dr. Greene, wanted to start him out slowly. He also knew that paramedics could bring in a trauma patient at any time.

After his lunch break, Tom didn't have long to wait before the paramedics burst in through the swinging double-doors of the ambulance bay wheeling in a young man on a gurney. Edward, a veteran EMT, recited the vital signs to Tom and Dr. Greene as they helped push the gurney into the trauma room. "18-year-old male, GSW to the right abdomen, heart rate 92 beats/minute, respiratory rate 22 breaths/minute, blood pressure 95/65, no loss of consciousness." Tom knew that gunshot wounds were sometimes the most difficult traumas to handle.

Once inside the trauma room, Dr. Greene began his initial assessment of the patient while Tom organized the things he knew would be needed. He attached a pulse-ox monitor to the patient's index finger so Dr. Greene could keep an eye on the O2 levels in the patient's blood and he inserted a Foley catheter so the patient's urine output could be monitored.

After finishing his initial duties, Tom heard Dr. Greene say "It looks like the bullet missed the liver and kidney, but it may have severed an artery. That's why his blood pressure is low. Tom, grab a liter of saline and start a fast IV drip...we need to increase his blood volume." Tom grabbed one of the fluid-filled bags from the nearby shelf, attached a 12-gauge IV needle to the plastic tubing, and gently slipped the needle into the patient's antecubital vein. He then hung the plastic bag on the IV stand and let the fluid quickly start to flow down the tubing and into the patient's vein.

The reaction was quick and violent. The patient's heart rate began to skyrocket and Tom heard Dr. Greene shouting, "His O2 saturation is falling! Pulse is quickening! What is going on with this guy?" Tom stood frozen in place with fear. Dr. Greene continued. "Flat line! We've lost a pulse...Tom, get the crash cart, we need to shock the patient to get his heart going again!" Tom broke free from his initial shock and did as Dr. Greene had ordered. He then started CPR as Dr. Greene readied the cardiac defibrillator to shock the patient. They alternated between CPR and defibrillation for half an hour, but to no avail. As Dr. Greene announced the time of death, Tom felt sick. He couldn't believe that his first trauma patient died.

Then Tom noticed that the fluid in the Foley catheter bag was bright red. "Dr. Green, there's hemoglobin in the Foley bag," he said. "How could that be?" responded Dr. Greene. Tom began to trace back his steps, trying to think of anything that could have caused the hemoglobinuria. His mounting fear turned to outright terror as he looked at the now empty bag on the IV stand. Its label didn't read "Saline" but rather "Distilled Water." He looked at Dr. Greene, his heart quickly sinking, and said, "I think I killed the patient."

QUESTIONS:

1. How would you describe the tonicity of the distilled water that was administered to the patient compared to blood?

2. Blood is composed of plasma and formed elements. Plasma is the fluid portion of blood while formed elements are the blood cells - red blood cells, white blood cells and platelets. Under normal circumstances, plasma is isotonic to the intracellular environment of the red blood cells.

Describe the movement of water into and out of red blood cells when in their normal isotonic environment. How does this movement of water impact red blood cell size?

3. How did the distilled water impact the tonicity of the plasma relative to red blood cells?

Describe the movement of water into and out of red blood cells after the distilled water was administered. How did this movement of water impact cell size?

4. Considering the function of RBCs, explain why the patient's oxygen level fell.

5. Why do you think hemoglobin appeared in the patient's urine (hemoglobinuria)?

6. If Tom or Dr. Greene recognized the error earlier, could they have done anything to try to save the patient's life?

7. Describe how a hypertonic IV solution would impact red blood cells.