Keywords

Case Scenario

An 84-year-old American Indian woman is brought to the emergency department at a tertiary care hospital by Advanced Life Support ambulance from an Indian Health Services clinic on a Pueblo approximately 2 hours away. She is accompanied by her daughter, who brought her to the clinic from home due to cough and fever. She is a frail-appearing older woman in a hospital gown, lying under a traditional blanket. She is on oxygen by non-rebreather. The patient is somnolent but easily arousable to voice. She speaks some English, but Navajo is her primary language. The resident has difficulty understanding her responses and is not certain that the patient understands her questions.

The clinic chart reports that a chest radiograph was obtained, which revealed a right middle lobe pneumonia. Labs were obtained, which were remarkable for an elevated white count and elevated blood urea nitrogen (BUN ) with normal creatinine. The clinic gave the patient 1 liter of normal saline IV fluid and antibiotics appropriate for community-acquired pneumonia. Copies of the medical record, laboratory results, and radiologist’s read of the X-ray are included.

The resident asks the patient’s daughter about the patient’s history and review of systems. She explains that the patient will be admitted to the hospital for antibiotics, oxygen, and IV hydration. She asks the patient’s daughter if she has any questions. The daughter says, “No.” The resident exits the room to begin the treatment and admission of the patient.

Review of Symptoms

According to the clinic chart and the patient’s daughter, the patient ordinarily is ambulatory and independent in the activities of daily living. She lives with her daughter and the daughter’s family. The daughter said that she hasn’t been eating well for about a week. She has been in bed for 2 days and seemed to be having trouble breathing this morning. No other symptoms were recorded .

Past Medical History

Right hip fracture 2 years ago. Repaired.

Per clinic chart:

Influenza vaccine this year and has never received a pneumovax

Family History

Children with diabetes and hypertension, parents died of “old age”

Social History

No alcohol or tobacco use by the patient, patient worked at home as a weaver

Physical Exam

Vital signs: Temp: 101.3 °F, pulse: 104, BP: 90/55, respirations: 24, O2 Sat 90 % on 10 liters by non-rebreather mask

General: Thin, frail-appearing older American Indian woman, somnolent but arousable to voice

Cardiovascular: Tachycardia in regular rhythm, with no murmurs, gallops, or rubs, palpable radial pulses

Respiratory: Tachypnea, shallow respirations, crackles in the bilateral lower lung fields; coarse breath sounds on right

ENT: Pupils round, r eactive to light, arcus senilis, conjunctiva normal, mucous membranes dry, poor dentition

Abdomen: Soft, non-tender, non-distended, no organomegaly

Extremities: No edema, 4+ strength throughout, no cyanosis, arthritic changes to hands

Skin: No rash

Neuro: Grossly intact, no focal deficits

Neck: No jugular venous distention, bruits, no stridor

Questions for Discussion

  1. 1.

    Why is communication with the patient difficult?

    Attitudes/assumptions: The physician

    1. (a)

      The patient does not speak English well.

    2. (b)

      The patient does not understand my questions.

    3. (c)

      The patient may have dementia or other memory loss.

    4. (d)

      The patient is uneducated and wouldn’t be able to give a medical history.

    5. (e)

      The patient’s daughter can speak for her and will make health decisions for her.

    6. (f)

      The clinic’s record is adequate because that is where the patient gets her primary care.

    Cross-Cultural Tools and Skills: Language

    1. (a)

      Commercial interpretation services often do not include American Indian languages.

    2. (b)

      Institutions taking care of populations speaking American Indian languages often have interpreter services available.

    3. (c)

      Younger family members are often bilingual. Elder American Indians will often be accompanied by family members who wish to help with their care. This raises the ethical issue of using family members as interpreters.

    4. (d)

      In some American Indian communities, asking questions is a sign of disrespect. Simply asking if a patient or family member has any questions may not be adequate to explore their understanding.

    Cross-Cultural Tools and Skills: Patient Autonomy

    1. (a)

      Elders are considered autonomous and make their own health decisions if they are able.

  2. 2.

    How should the physician approach issues of code status and goals of care?

    Attitudes/assumptions: The physician

    1. (a)

      The patient won’t understand or be able to make her own decisions regarding her goals of care or code status.

    2. (b)

      She and her family will be offended if code status or goals of care are brought up.

    Gaps in Provider Knowledge

    1. (a)

      Lack of understanding of elders’ autonomy.

    2. (b)

      Lack of knowledge regarding this specific community: Learn the family dynamic of elders living with extended family and expectation regarding elders’ participation in decision making.

    3. (c)

      Lack of knowledge of disparities/discrimination: American Indians may be distrustful of western medicine and the healthcare system, both internal and external to the Indian Health Service, due to a long history of misuse by researchers and transient healthcare workers with little understanding of their culture [1].

    4. (d)

      Lack of knowledge of health beliefs/customs by provider including traditional medicine and the importance of medicine men.

  3. 3.

    Which components of the Emergency Medicine Milestones of the ACGME competencies are incorporated in the case? [2]

    • Patient Safety : Participating in an institutional process improvement plan to optimize emergency physician practice and patient safety.

    • Systems-Based Management : Recommending strategies by which patients’ access to care can be improved.

    • Professional Values: Demonstrating behavior that conveys caring, honesty, genuine interest, and tolerance when interacting with a diverse population of patients and families and demonstrating an understanding of the importance of compassion, integrity, respect, sensitivity, and responsiveness, and exhibiting these attitudes consistently in common/uncomplicated situations and with diverse populations

    • Patient-Centered Communication : Effectively communicates with vulnerable populations, including both patients at risk and their families.

Case Outcome

Diagnosis: Right middle lobe pneumonia and sepsis .

Disposition: Patient was made full code and admitted to the intensive care unit (ICU ), where she initially deteriorated and required bilevel positive airway pressure (BiPAP ). The family requested that their medicine man be able to visit. He performed several healing ceremonies. The patient made a slow recovery, complicated by a troponin leak and deconditioning. She was discharged to a rehabilitation facility 21 days after admission.