Ms J, aged 45 years, was a nurse practitioner who worked in the emergency department of a small regional hospital. She had been working at the hospital for the last decade and was well regarded among her peers. On the day in question, a Tuesday, Ms J’s shift began at 6 am. She was relieved to see that the emergency department seemed quiet. 

She had just poured herself a cup of coffee when she got a call from the floor nurse in the intensive care unit (ICU). 

“We’re sending someone down to the emergency department,” the floor nurse said. “Her name is Mrs B. Her mother is in the ICU, and Mrs B stayed in the mother’s room overnight. She slept on two chairs last night, and this morning she was complaining terribly about pain and swelling in her right ankle. I’ve told her to go down to the emergency department to get looked at.” 

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“Okay,” Ms J said. “Anything else I should know?” 

“She’s wound up pretty tight,” the floor nurse said. “She’s very concerned about her mother, who isn’t doing well. She’s a little worked up.” 

Ms J thanked the nurse for the information and waited for Mrs B to arrive. When she did, Ms J ushered her into an examination room. 

The patient, aged 60 years, told Ms J that her 85-year-old mother was in the ICU with congestive heart failure and that she had stayed with her overnight. 

“She gets agitated if she’s alone for too long,” the patient said of her mother. “I thought it would be a good idea to stay last night, and I slept on two chairs that I pushed together. But when I woke up, my right ankle was killing me. I don’t know why.” 

Ms J examined the ankle, which was swollen and clearly painful. Other than the swelling and pain, there were no signs of anything abnormal—no redness or heat. Ms J concluded that the injury was a sprained ankle, and she placed the patient’s right foot in a splint to help it heal. 

“Try to rest it,” she told the patient, “and either see your own doctor or come back here within the next two days so someone can check the splint.” 

Ms J noted in her file that the patient had been instructed to follow up with her own physician or the emergency department within 48 hours. She wished the patient well and ushered her out of the examination room.