Jamal Phiri is a Canadian-born 17-year-old diagnosed with asthma at the age of 9. He identifies as a transman and uses the pronouns he/him. Since then he has had four pediatric ICU admissions for acute asthma exacerbation, one in which he was intubated. He has no other past medical history and is currently taking Breo Ellipta daily with occasional use of rescue inhaler Ventolin. Jamal recently decided to go back to school as opposed to virtual schooling during the COVID-19 pandemic against his mother’s advice. He is an only child and lives in a single parent home with his mother who works 2 jobs. Jamal’s father blamed the mother for their “daughter’s” gender identity and abandoned the family. He has been following up with his family doctor, however, Jamal has rescheduled his consultation with the respirologist 3 times. He asks the healthcare team to use the preferred name of Jamal.
For the past 3 days he has been having increased shortness of breath not completely relieved by his rescue or maintenance inhaler. Jamal was sent to the emergency department by the principal when he was found to be short of breath after participating during the gym class. Presenting to the emergency department he has a temp of 37.9°C, 2-3 word dyspnea, audible wheezes, and accessory muscle use. Jamal’s past medical visits are well documented within his medical record and after the physician assesses Jamal, he orders an urgent consultation with the ICU physician while Jamal is stabilized by the nurse and respiratory therapist. Jamal had a septic diagnostic tests completed (CBC, electrolytes, blood cultures x 2, lactate level, venous blood gas, urinalysis, chest x-ray and a COVID-19 swab) and is placed on Bilevel Positive Airway Pressure (BiPAP) by the respiratory therapist. Jamal is being administered steroids, bronchodilators, and antibiotics when the ICU physician assesses and admits him to the ICU.
You are Jamal’s ICU nurse and are receiving a report from the emergency nurse who states that Jamal’s blood chemistry and venous blood gas are pending as the first samples sent where hemolyzed and could not be analyzed by the lab. The emergency nurse states he attempted to call his mother three times with no answer and left two messages with call back information. After receiving the report, you assess Jamal and get him settled into his bed as the respiratory therapist adjusts the BiPAP mask. While putting his belongings away you noticed that Jamal’s medications were last refilled about two months ago. At this time, you note the following in his blood work: pH 7.30, PaCO2 39 mmHg, HCO3 19.5 mmol/L, lactate 15, potassium-2.8 mmol/L, and magnesium 0.51 mmol/L. You call the physician and inform her of the lab values, and she orders for electrolyte correction and repeat blood work 1-hour post administration.
After administering ordered medications, you call Jamal’s mother again and she answers. When speaking to her you realize that she is often not home and most of the responsibility of filling his prescriptions, taking daily medications, and getting to and from appointments falls on Jamal. She was also upset to find out that Jamal had returned to school as she received a call from the principal as well. Furthermore, she states she will not be able to come in until she is finished her shift in 2 hours.
As Jamal stabilizes and is down-graded to 40% FiO2 face mask you start asking him about his medications and triggers leading up to exacerbation. He believes that exercise could have been a factor of this exacerbation as he has not been able to renew any of the prescriptions due to his lost health card. He states that due to being busy with finishing up his last school year he has not had time to see his respirologist of renew his health card. As Jamal is answering your questions, his mother arrives and begins to engage in the conversation.
When Jamal is stabilized enough and ready to be transferred to the medicine unit you give a report to the medicine nurse and suggest that before discharge home there is a family meeting with the interprofessional healthcare team to review his current plan of care, medications and follow up appointments to identify areas that need adjustment due to his asthma.
Case Study Expert Reviewer: Dr. Erin Ziegler