describes herself as an active, athletic, and healthy woman. In her mid-forties she continues to run 2–3 miles 5 days per week

Lilly Walden describes herself as an active, athletic, and healthy woman. In her mid-forties she continues to run 2–3 miles 5 days per week. Lilly is married with three children and is employed by the local school district as a speech therapist. Lilly’s husband Tom is a pilot and he works for an international airline.

Lilly describes herself as health-conscious. Her diet is balanced, and she is a nonsmoker and drinks wine on rare social occasions. Lilly has a history of asthma, triggered by environmental changes, and it typically requires antibiotic therapy for bronchial infections 2–3 times per year. This morning, Lilly is awakened by mild intermittent right lower quadrant pain and a slight fever. Lilly applies a heating pad to the area and prepares a cup of tea that she hopes will help relieve what she believes are “gas pains.” During the next hour the pain and fever appear to be lessening and Lilly proceeds preparing herself and her children for school.

Around 10:30, Lilly notices that the pain in her right lower quadrant has returned. She is sweating and concerned that she may have a worsening fever. She contacts her supervisor and informs her that she is going to be out sick for the rest of the day. She telephones the office manager for her primary care physician, Dr. Maureen Woods, and requests an office visit.

Dr. Woods’ office manager is trained in the use of a practice-specific triage protocol, the details of which are outlined in a standardized computer algorithm. Patients with routine or non-urgent concerns are slotted into open appointment blocks, whereas more urgent issues (including Lilly’s call) trigger a telephone handoff to the nurse practitioner who is assigned to triage for that day. The nurse practitioner conducts a telephone interview and instructs Lilly to come directly to the physician’s office to be seen before the practice closes for lunch

When Lilly arrives in the office, the medical receptionist expresses concern regarding Lilly’s appearance, escorts her directly into an examination room, and notifies the registered nurse that Lilly is in Exam Room 3. Vital signs are checked using office protocols; extra parameters (also protocol-based and pre-determined) are included in the nursing assessment due to Lilly’s poor appearance. Her temperature is 102°F, and her heart rate is rapid. Lilly is noticeably sweating and has her hands placed over her right lower quadrant. The nurse asks the medical assistant to interrupt Dr. Woods who is in the next examining room seeing another patient so that she can evaluate Lilly due to her level of distress.

Dr. Woods excuses herself from her current patient and arrives at Lilly’s room to complete a focused examination. Dr. Woods informs Lilly that based upon her symptoms, she will need to be transported to the emergency room for evaluation of her pain and asks if her husband is in town or away on assignment. Lilly tells Dr. Woods that her husband’s return flight landed about an hour ago and he should be reachable by cell phone. Dr. Woods obtains Lilly’s consent for transport, instructs the nurse to stay with Lilly, asks the medical assistant to telephone for an ambulance, and then excuses herself to notify the emergency room of Lilly’s condition and her pending arrival. Other patients are informed by the office manager (also per a rehearsed protocol) that Dr. Woods is managing an emergent situation, but they will be seen as soon as possible. These patients are given the option of rescheduling if they are unable to wait or being seen by the nurse practitioner assigned to triage who will take patients in the order of their prescheduled appointment.

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