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Saturday

Second Victim

I'm at a nursing conference.  There was a lecture option called "The Second Victim of Infusion Therapy- Related Adverse Events", basically "Guilt from Making Medical Mistakes".
I couldn't even walk into the conference hall.

Twenty years after It happened, I still feel such shame, fear, and guilt about that shift that I cannot discuss it except among my closest confidants.  Those few discussions have been opportunities to teach other nurses about the dangers of infusing even the simplest of meds to patients in our care.

My family does not know.  The family of that patient does not know.   The only other person outside of my own medical community that has heard this story is my therapist.   I told him about it as I opened up about the most shameful events in my life.  (Besides the story I will share, he heard about childhood molestation and the divorce of my parents.  A shame spiral can be born of varied ingredients to be sure!)

Realizing that many of you reading this may not be nurses I will tell it as clearly as possible without: A.) making the medical jargon confusing B.) revealing any identifying details of the patient or her family or C.) attempting to persuade you of my own guilt or innocence.
Many reading MAY actually be nurses.  We tend to be a very caring community and some of you encouraged me here at this very conference.   Those that regularly read this blog are friends, family, and past members of our support group (many of YOU were nurses and other caring professionals).
Also taken into account is the fact that some of you (though not medically trained)  have watched Gray's Anatomy or Code Black.  In that case, keep up!

This event happened more than 20 years ago.  Technology and safety measures have improved and systems put in place to prevent this sort of incident from happening today.  Events that DO occur are handled much differently today as well.  Even so, my heart is racing and hands are shaking even as I type...

Fresh out of nursing school I was hired in the ED of a large Level I Trauma Center in a Teaching Hospital.  This was not common practice but I had worked in this ED as a student and the staff was pleased with my performance.  My preceptor was a former Army Captain and a real no-nonsense, authoritative, high expectation kind of woman.  (Translate: a real bitch).  She grilled me mercilessly and forced me to Be All I Could Be whether I had enlisted or not; she was an excellent motivator to know my shit.  Embarrassing me in front of other staff did not seem the least bit out of line to her.  Even Residents on their Trauma rotations sympathized with me when she demanded answers, calculations, and algorithms at the bedside of critically ill patients.  Several months into my first year she deemed me capable of caring for patients independently.  Midshift and after work she would ask me for report on all I'd done and advance my knowledge further with a battery of questions, comments, and even demonstrations of techniques or equipment I hadn't had the opportunity to use in the day's practice.

Because this particular day was busy and staff was short we were separated.  I was working independently.  In this ED we used one side of the department for Critical Care and Trauma and the other side for more minor illnesses and injuries.  We called it Trauma Side/Clinic Side.  Though all nurses on duty cared for all patients, we assigned a room or a block of rooms to each nurse to assure none were left unattended.  I was working Clinic Side.  Army Charlie, my preceptor, was Trauma Side.  There were about 5 rooms along the front hall that would be under my charge for 12 hours.  I took report at 7am and began caring for half a dozen patients; my rooms plus an extra few on the back orthopaedic hall.
     In one of the front rooms, directly across from the Nurses Station was a Sickle Cell patient.  She was resting fairly comfortably and had received about a liter of D5W/IV fluid.  Typically Sickle Cell patients came in because they were in a pain crisis; excruciating pain requiring narcotic pain relief and, often, a hefty amount of hydration.  This Dear Lady was on the stretcher with her IV in place and fluid running at about a liter/hour.  She needed lots of fluid today and would likely be with me for most of my 12 hours.  I greeted her, checked her IV site and drip rate (in those days we simply counted the drops per minute in the drip chamber and controlled the rate with a roller clamp).  She smiled and thanked me right off for being so nice.  "That last nurse was so mean and rough", she complained.  Indeed, her night nurse who had just given me report had complained that this patient was a "frequent flier that needed juicing up".  She was a harsh old trauma nurse that didn't like being assigned to clinic side doing "the easy stuff".  Though she was skilled, she wasn't kind.  I assured my Dear Lady that I would be with her through the day and was happy to give extra TLC as needed.  I went to read her chart and see what she'd need.  (Again, the ancient day of paper charts piled on a desk. Doctors could write orders on the front page.  Nurses turned to the next section to hand write notes and Assistants added vital signs and lab results as they were obtained.  All pen on paper and photocopied pages.)  She'd received her narcotic and only needed fluids while lab results were pending.  I got a dose of antidote to her narcotic and put it in my pocket with her name on it.  (Again, that's how it was done "back in the day".)

"Clinic" got busy in a hurry.  I checked in on my patients and flew about from task to task for about 8 hours.  My Dear Lady was still in the room up front.  I'd given her a dose or two of pain reliever through the shift and kept her comfortable but awake.   I shouted across the desk to the Attending to see if he wanted me to change her to a different solution.  "Give her another round of D5" he'd replied.  I did.  This bag was slowed so that it wouldn't need to be changed again in the last 4 hours of my shift.  I saw kids with asthma, pulled a roach out of someones ear, and helped a doctor put a cast on a fractured humerus.  When I next checked through my charts the Dear Lady had an Xray ordered.  I went into her room to wheel her down the hall myself.  She seemed drowsy, but spoke to me.  Half way to the Radiology Suite in the ED I had a sick feeling in the pit of my stomach.  I stopped and looked her in the eyes and asked a few questions to check her mental status.  She groaned and lost consciousness.  I'd seen this happen a few times with Sickle Cell patients.  Often another nurse may have given a dose, or even several doses, of narcotic without my knowledge.  It would be written on the chart.  I checked.   Indeed, the doctor had ordered and the charge nurse had given a dose while I had been wrangling roaches and slinging cast supplies.  Though it didn't seem to be an unusual amount of narcotic, the first and best response is to reverse it when a patient's mental status suddenly changes.  This antidote causes and quick and dramatic reversal of the narcotic's effects.  Frankly, the administration of this drug is very satisfying to administer.  The patient arouses immediately and, though the pain returns as well, stopping the effect of the narcotic brings the patient right back to "reality".  Like a slap in the face it brings them back from the brink of overdose.  I called out loudly for help and notified everyone around me what I was doing.  "Narcan in!"  is something of a battle cry.  Other staff might stop and watch your patient wake with the same satisfaction you feel as you administer the life-saving dose.  Indeed, I felt a surge of satisfaction that I had been well prepared with her dose in my pocket.  Army Charlie had trained me well so that others would be alerted to both my dilemma and the imminent return of Dear Lady's consciousness.

But she didn't regain consciousness.  She lay there unresponsive despite my intervention.  I switched sides of the Stryker frame and began pushing her toward the Critical Care side.  As I passed back by the Nurses Station the charge nurse called out to me, "hey, I need to chart on her- I hung another bag of D5W for you".  I looked at her with horror.  "Help me".  Was all I could say.  She joined me in heading to a telemetry room as I told her of the events of the past few seconds.  I checked the syringe in my pocket.  I'd given the right dose to the right patient.  She pushed on- I went back to the patient's room.  I thought I was going to tell a family member that we were moving her, but the bucket trash can caught my eye.  There were several empty fluid bags in the trash can.  I don't remember if I even spoke to the man that sat next to where my Dear Lady's bed had just been.  I examined each bag and ran for the Critical Care room.  In the hallway before I reached it stood Army Charlie.  "What the hell have you done?"

I don't know if that is really even what she said to me.  But that is what I remember hearing.

There had been at least three other nurses "helping me" care for this Dear Lady.  All totaled she had received at least 5 liters of D5W.   There were so many mistakes made in the care of this patient.  The fact remains, she was MY patient and I assured her that I would care for her.  She died the next day in the ICU.  There have been very few days that have gone by since then that I haven't thought of that dear lady... or my preceptor's question.  "What have you done?"



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