I Wasn't Always This Strong - part 7

As a nurse I have learned to pay attention to my gut.  I may not have as much education as everyone around me but I know my gut feelings have never steered me wrong.  On this particular night in the NICU I was taking care of a very sick baby who was on a ventilator.  Paul had severe lung disease and was totally dependent on his ventilator.  As I cared for him during the night something changed.  I couldn’t put my finger on it but something did not seem right.  At the time we did not have O2 monitors to monitor the oxygen in their blood.  To get that value we would have to do an arterial stick and run the blood down to the lab.  We did this as infrequently as possible so as not to traumatize the babies.   I finally called the respiratory therapist in to take a look.  He stopped in and checked the baby out but told me the settings were right and he didn’t see anything wrong with the baby.  But still I was not satisfied.  I had been working with this baby the past few nights and knew in my heart that something was not right.  Being a fairly new nurse I did not question the respiratory therapist.  Surely he would know if something was wrong.  But I did have an uneasy feeling the rest of the night.  Finally morning arrived, the shift changed and a more experienced respiratory therapist came in to get report.  He took one look at the baby and said “What is going on here?!”  He took a blood sample and sent it to the lab.  He had immediately detected what I was noticing all night long.  The blood gas values came back and he quickly made adjustments on the ventilator.  Within minutes the baby looked much better.  I had been right with my concerns.   

In a similar scenario I was working on a Post Partum unit with new Moms.  One of my patients had a Cesarean Section and was complaining of post nasal drip and just “feeling bad”.  I couldn’t find anything obviously wrong but paged the resident to let her know that I thought the Mom should be checked out.  The resident did not respond to her page and I paged again and again.   She finally came up to the floor and in front of my coworkers she lambasted me for bothering her.  Then, at my insistance, she stopped by the Mom’s room and the first thing she did was listen to her lungs which I had failed to do.  She turned to me and said her lungs are full of fluid, get me some lasix (a diuretic) immediately.  We gave her the lasix and she put out 1500 cc of urine!  We had been filling her with fluids and she was not peeing it back out so it was collecting in her lungs.  If left untreated she could have gone into respiratory failure.  From that day on, no matter how difficult, or how angry I knew a physician would be for being called, I always made the call and insisted until someone saw any patient I was concerned about.  

Just a few weeks after this experience I arrived at my job and was told that Ann Scott, another new Mom who had had a Cesarean Section, had died in the night.  To say I was shocked was an understatement.  We never had deaths on the Post Partum Unit.  It seems that in the night Ann was getting a little short of breath.  The nurses spoke to the resident on call and asked for him to come up to see her.  He was busy and said he would get there when he could.  Ann continued to get worse.  The nurses became increasingly concerned and called again.  This time the resident did not respond.  They called the attending, waking him at his home.  He admonished them for calling him and told them to contact the resident.  By this time they had put Ann on oxygen and were beginning to panic.  The resident finally returned their calls and told them he would be up as soon as he could.  But they couldn’t wait.  They knew something was seriously wrong.  They decided to take matters into their own hands, taking Ann up to the ICU, bed and all.  On their way Ann stopped breathing and coded.  They called for help and started doing CPR but it was too late.  Ann had died by the time they reached the ICU.  The day shift nurses sat in abject horror as this story was related to us.  Our mouths hung open as we couldn’t take in the enormity of this tragedy.  There was silence in the report room.  We all looked at each other trying to make sense of Ann’s death.  Her husband would be returning home with a newborn baby and no wife,  making his way through his grief as well as the unchartered territory of parenthood without his baby’s mother.  How could this happen?  

Every hospital has what they call the M&M Rounds - Morbidity and Mortality Rounds.  At these rounds only the most difficult cases are discussed.  These cases are the ones where something went wrong, someone made an error in judgement, the course of treatment did not go as planned or there was unintended injury or death.  Not everyone is invited to these rounds for obvious reasons.  They are by invitation only, considered to be extremely confidential and meant as a learning tool so that the people involved can look at the entire situation with their contemporaries to hopefully keep this type of situation from ever happening again. 

I attended the M&M Rounds regarding Ann Scott.  After picking through the chart line by line and discussing every angle of the incident it was decided that Ann had literally drowned in her own fluids.  She was given much more IV fluid than she was putting out and no one had noticed.  The nurses had not kept good records of her intake and output and the resident and attending physician had not responded appropriately when called.   And because of that seemingly small but very significant error, a man lost his wife, parents lost their daughter and a baby lost his mother.