A 42-year-old woman presented to a busy urban
emergency department (ED) and approached the triage nurse. The
patient told the triage nurse that she had "3 days of face and
tongue swelling." She also said that, in the previous 2 weeks, she
had two intensive care unit (ICU) admissions for similar complaints
and that she had required intubation in one of those instances.
The triage nurse documented that the patient was
"speaking in full sentences" and "swallowing secretions." The vital
signs at triage, including respiratory rate and oxygen saturation,
were normal. The triage nurse decided that this was "urgent" and
not "emergent," and therefore the patient was asked to wait in the
The patient sat in the waiting room for more than
2 hours before she was finally placed into a room in the ED. It was
another hour after that before a physician evaluated her. By that
time, her tongue and throat had swollen substantially, and she was
having difficulty breathing. She required emergency intubation, a
potentially dangerous and high-risk procedure, and aggressive
treatment with intravenous epinephrine, steroids, and
The patient was given a diagnosis of
angioedema—rapid swelling of the skin and tissues around the
mouth and throat. She was admitted to the ICU and had an
uncomplicated 5-day hospital stay. The patient experienced no major
The case was discussed in the departmental
quality conference. When asked why she did not bring the patient
into the ED more emergently, the triage nurse responded, "I didn't
think the patient was telling the truth about her recent
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