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Today is a good day

Aul, Karen, PhD, RN, CNE

doi: 10.1097/01.NURSE.0000541388.52104.2c
Feature: Sharing

What was the source of this patient's mystery infection?

Karen Aul is a clinical assistant professor at the University of Florida College of Nursing in Gainesville, Fla.

The author has disclosed no financial relationships related to this article.

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AS A NEWLY LICENSED graduate nurse, I wasn't sure where to begin. When I went for a job interview at a large metropolitan hospital, I was asked, “What type of unit do you want to work on?” I didn't have any obvious favorites, but I chose the cancer unit. I'd cared for several oncology patients as a nursing student, and I'd felt challenged trying to provide quality care to them.

One of my first patients was a middle-aged man I'll call Ricky. Ricky was diagnosed with non-Hodgkin lymphoma (NHL) and was receiving multiple chemotherapy drugs. He'd been admitted with Stage IV recurrent NHL and his prognosis was poor. Despite his unfavorable odds for survival, he always had a smile on his face. I wondered why.

While administering his chemotherapy, I had the opportunity to talk with him. He told me he was just happy to be alive. “I take one day at a time. I'm thankful each day I wake up. Today is a good day,” he said. Ricky responded well to treatment and was discharged.

Two weeks later, Ricky was readmitted with an infection of unknown etiology. We obtained cultures and started him on a broad-spectrum antibiotic, pending final culture and sensitivity results. After 2 days, Ricky's clinical status hadn't improved. He was still being treated for an infection, but his culture results were all coming back negative and the infection source remained unknown. His oncologist called it a “mystery infection.”

As I completed a second assessment, the gold ring on Ricky's right hand caught my eye. I asked, “Ricky, when was the last time you took that ring off your finger?”

He replied, “Well, I never take it off. I haven't taken it off in 20 years.”

“Can you take it off now so I can assess the skin underneath it?” I asked.

He tried twisting the ring gently back and forth while slowly pulling on the ring, to no avail. The ring was stuck on his finger. After trying and failing to remove it with some lubricating products, I located a ring cutter in the ED. Ricky, although somewhat sorry about damaging the ring, agreed to the procedure. As it was gently removed, I saw an open erythematous wound with some purulent drainage. I exclaimed, “That's where the infection is coming from!” We could now start definitive antimicrobial treatment guided by results of the Gram stain, wound culture, and sensitivity.

Ricky smiled from ear to ear. “Today is a good day!” he said.

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