by Tilda Shalof
Three o’clock in the morning feels like the middle of the night, but there are only four more hours to go. Monica has returned from her “break,” looking flushed and more energized than anyone has a right to at this hour of the night. She is shocked when I tell her about Tikki’s iPod and bad attitude and asks me what I am going to do about it. She tells me I’d better keep my eye on her and document the problems with her work. “If you see something wrong, it’s your duty to do something about it,” she reminds me and I know she’s right.
Tikki is not too pleased when I show at her side once again. I hate policing people, but when I take one look at her patient’s flow sheet, I immediately see a problem that could be serious. “Tikki, did you notice your patient’s cardiac output?”
“Yes, I did,” she says slowly. “It’s 2.3 litres per minute.”
“What did you do about it?”
“I mentioned to the doctor it was low,” Tikki said defensively, “but she didn’t react.”
“You have to recognize the significance, make a fuss, and follow through,” I say, trying to goad some reaction out of her, but she only looks wounded and starts to explain herself. Suddenly, across the room, there’s a scream and a moan.
“Help! I need help!”
It’s Chandra. I leap over in two bounds. In moments, Roberta rushes in. Theo arrives, pushing the crash cart ahead of him, Jenna, Trina, and others right behind him. Chandra is slumped over the side rails of her patient’s bed, practically lying on top of her patient, her hands covering her face. “Shit, shit. I’ve made a terrible mistake.” She pulls herself upright and quells her terror long enough to tell us exactly what happened. “I hung what I thought was the antibiotic, but it was a bag of insulin – fifty units in a fifty cc bag. I got them mixed up. Instead of the antibiotic, I ran in the entire bag of insulin in twenty minutes. It was supposed to go in over twenty-four hours.”
She’s barely finished getting this story out and Roberta has already run to fetch the glucose analyzer to check the blood sugar and I am pushing two large syringes of Dextrose 50 per cent – D50 – a concentrated sugar solution, into the patient’s central intravenous line. Someone pages the doctor. We work fast. Chandra is in shock, stunned by what she’s done. Normally a self-possessed, take-charge sort of person who prefers to do everything herself, she’s backed right off and lets us take over, as if she’s forfeited her right to be a nurse.
Theo examines the patient, assessing his level of consciousness. He shines a light into his eyes and sees that the pupils are responding briskly, as they should. Someone draws blood to check electrolytes. As I place the electrodes on the patient’s limbs and chest for a twelve-lead ECG, I catch sight of Tikki, watching and looking smug. Surely she recognizes that this is an emergency? “He looks okay to me,” she says with a shrug of her shoulders and goes back to her own work.
“He may not be shortly,” I snap at her, glancing at the blood sugar result of 3.0 mmol/L.* Anything below 4.0 is dangerously low. Don’t you realize if we don’t take immediate action to rescue him, he will have a seizure, go into a coma, and have a cardiac arrest in a matter of minutes? I draw up a syringe of midazolam, the treatment for a sudden seizure, to have at the ready. The patient stirs in his sleep and we jump. Is it due to the commotion in the room or the sudden plummeting of blood sugar? Theo tries to shake him awake, but can’t rouse him. Whether it’s from insulin shock or from the sedation he’s already on, we can’t tell. I push in another – now the third ampoule of D50 and Roberta retests the patient’s blood sugar. It’s now 2.5 and could still drop further. “Is the doctor on her way?” I ask.
“She can’t come right now,” Roberta says. She’s starting a Dextrose 10 per cent solution and I push in another amp of D50, figuring that even if I overshoot, a high sugar level is less dangerous than a low one, and set my eyes on the cardiac monitor, on the lookout for arrhythmias. “She’s in emerge examining a patient who may have to come here and the young woman with the Tylenol overdose is crashing, so she has to go to her first, but she says we’re doing all the correct things.”
“How could I be so stupid?” Chandra moans. She paces the room, wringing her hands. “I wasn’t tired. I wasn’t overly busy. I wasn’t stressed out.” She stops in front of the IV pump, picks up the empty bag of insulin in her hand, stares at it, and shakes her head as she searches for clues to understand her mistake. I can imagine her desperate wish to take back those few moments of inattention, to return to the blissful, innocent time of “just before.”
“He’ll be okay,” I say, taking another reading, and see that the blood sugar is down to 1.6. I push in two more amps of D50. I think he will, anyway.
0400: The Correction
We’ve managed to get the patient’s blood sugar back to a normal range and so far, he does not seem to be experiencing any adverse effects from the mistake. I put my arm around Chandra, who is devastated. She pulls away and I understand her reaction. What I do not understand is Tikki’s.
The doctor arrives and says, “You saved her,” and doesn’t harp on the fact that one of us almost killed her. She is pleased we took control and agrees with everything we’ve done. She examines the patient, finds no abnormalities, and is satisfied that the mistake has been completely rectified. She and Chandra fill in an incident report that outlines all the details. In the morning, they will inform the manager and staff doctor, who will call the family to let them know what happened.
We all can see how hard it is for Chandra and we realize she wants space. She has retreated inward and is inaccessible. She’s lost trust in herself as a nurse. She’s trying to find her way back, learning to be a nurse all over again. She pulls away from us as if this self-imposed isolation is part of her punishment.
0500: On Guard
Who needs a “second wind” now? There’s nothing like a crisis like that to jolt me out of my fatigue! I return to my patient’s room and stand at the window to catch my breath, one eye, as always, on the monitor. It is quiet in the room, other than the bubble and hiss of his oxygen set-up. I look out at the city from the top of University Avenue, right down to Lake Ontario. I am rattled not only by the mistake and the nearness of fatality, but by Tikki’s nonchalance. What concerns me the most was that she was not concerned in the least. Her defence was that it wasn’t her patient. “They’re all our patients,” I said, “we work as a team.” Why do I have to tell you this? I wanted to scream at her.
The city sleeps. My patient sleeps. I note that his hourly urine has picked up from the diuretic that Noreen had given on days and that his cardiac filling pressures have also improved. His chest sounds clear and his vital signs are normal. He’s getting better.
A flashing blue light from the helicopter on the landing pad at the Hospital for Sick Children across the street flickers on the wall of my patient’s room. It was the aircraft that brought in the young woman that Casey is taking care of down the hall and it’s now preparing to take off to another emergency somewhere in the province. I have that nagging feeling I’ve had so often throughout my life, that I’m a lone, silent guardian and that it’s all up to me to take care of everything. But how silly, of course I am not alone. I am a member of a team.
0600: Almost There
“Hey, Tilda,” Roberta says, “do me a favour. Go check on the chaplain. I think he may be having a meltdown.”
I find him sitting outside the patient’s room, staring into space. As soon as I touch his shoulder, he bursts into tears. He apologizes and says he has encountered this sort of tragedy before, of course, but for some reason this one is really hitting him hard, perhaps because his own daughter is the same age as this young girl? He looks exhausted and seems traumatized. He probably should “debrief” but right now he needs to rest. I take him to a couch in the waiting room and cover him with a pile of blankets. He’s shivering and grateful.
0700: Morning Has Broken
I read somewhere that the noise during shift change is as many decibels as
a chainsaw. The team is arriving for the day shift and the nurses’ chatter and laughter may be annoying to patients, but to us night nurses, it’s the sound of salvation. We’re miners, deep down in the pit, hearing sounds of life from above. Rescue is on its way! (One does tend to get a bit dramatic when sleep-deprived.) The clean, fresh nurses start bopping in, energetic and vibrant, some smelling of shampoo, their hair still damp from their morning showers. We’re grubby and crabby and feel like hags and ogres. “Busy night?” the fired-up new ones ask us, graciously showing sympathy despite their sleep-saturated superiority.
“It was …” we look at each other to arrive at a consensus, “steady,” we concur.
After handover, we sign off our charts with “Report given,” and thus, relieved of our duties, we head off to the locker room where we dump our uniforms into the hospital laundry, change into our real clothes, and file out the door. We can’t wait to get home and take showers. Chandra is staying behind to report her medication error to the staff doctor and Jenna goes off to the cafeteria to drink coffee and eat pancakes to keep herself awake for her gynecologist’s appointment later in the morning, but the rest of us head off to the elevator. We give each other a quick once-over to check if anyone looks too bleary-eyed to drive home.*
We push out the door and plunge into the cool morning air, breathing deeply. Somehow, even the pollution and city smog smell fresher than the recycled hospital air we’ve been breathing all night. If the sky is overcast or if it’s raining, we congratulate ourselves on the good sleeping conditions, but if the sun is boldly shining, mocking our upside-down lives, we moan about the beautiful day we have to waste by sleeping. We go our separate ways, calling out “good night” to one another.
I zip along the streets, happy to be going in the opposite direction to the flow of downtown traffic. I’m ready to get into bed as soon as I get home, but there have been many mornings after a night shift when I’ve been too buzzed to go straight to sleep. Many nurses tell me they have insomnia and have to hang heavy curtains on their windows to keep out the blazing sun and wear earplugs to muffle the noise of construction, traffic, doorbells, and barking dogs. Not me, I can sleep under any conditions. But I do linger a few minutes longer, enjoying the quiet and having the house to myself, before crawling into bed, joined only by Digit, our six-toed calico cat who perhaps understands best, as she is nocturnal, too.
* Please note: The following would be a good passage to read if you are trying to lose weight. It may be an effective appetite suppressant.
* Though not a tattoo, still noteworthy body art in its own right.
* International Units.
* More times than I like to recall, I’ve had to pull over to the side of the road for a rest before continuing home. Once, I think I was actually sleeping while driving, but I’m not sure.
12
NIGHTMARES
Harming a patient is every nurse’s worst nightmare. Nurses know that even giving the correct medication at the wrong time, or missing a single dose of a drug is an error. If a doctor writes an order that is incorrect in any way and the nurse gives the drug as ordered, the nurse has also committed an error. Every nurse I know does everything possible to give safe care, but if I knew a nurse who was unsafe, I’d be just as wrong if I didn’t do something about it. We’ve all made mistakes, fortunately most of them not as serious as Chandra’s accidental insulin overdose. That problem was corrected, there were no consequences to the patient, and although the family was understandably upset, they accepted the apology offered. But since then, Chandra has been off work and has told me privately that she has decided to leave the ICU. Her confidence has been thoroughly shaken.
That night I realized I had my own nightmare waiting to happen: Tikki. When I saw her stand by in the aftermath of Chandra’s potentially fatal error and not rush to assist her nor appear to comprehend its serious implications for the patient, I realized that Tikki was not a safe nurse. As her preceptor to the icu, it was incumbent upon me to do something about her, and fast.
Tikki was intelligent and skilful, but did not show good judgment. Another problem was her attitude. She was cocky and fearless: she didn’t know what she didn’t know and not being aware of deficiencies in your knowledge is a dangerous thing in a nurse. You have to have a degree of caution, the ability to recognize subtle changes and pick up on warning signals, and ask lots of questions. You have to keep an active sense of wonder and not jump to conclusions. You have to have a sense of fear and awe and if you don’t feel that edge, that’s a serious problem. Tikki had way more confidence than she deserved. She never paused to consider, think things through, or question herself; she just plunged right into situations. I once saw her inject a medication through a patient’s naso-gastric feeding tube without ensuring beforehand that it was positioned correctly in the patient’s stomach.
“No worries,” she said blithely when I mentioned it to her.
“It might have been too high up or in the trachea and the patient could have aspirated into his lungs. You have to always check it first.”
She verified that the tube was in fact in the correct position. “See, it was fine all along,” she said. “You were worried for nothing.”
I wasn’t the only one who had become uneasy about her.
“Why are you still sitting on this?” Monica took me aside on the next shift we worked together after the night of Chandra’s insulin error. “Are you documenting the problems? Have you spoken to our manager? Are you on top of this, Tilda?” She was about to launch into her own litany of complaints against Tikki’s nursing care, but I stopped her. I had enough evidence of my own. The question was, what was I going to do about it? She had only been working in the ICU for a short time and I had wanted to give her sufficient time to adjust and prove herself. But after that night, I realized that by doing nothing, I might be allowing something terrible to happen.
The next day we worked together, I told Tikki she had to continue to work under my supervision. There were more skills that I needed to observe her perform, I told her. I had concerns about her nursing care. She scowled. Throughout that day she pretended to listen when I pointed out problems, but then I saw her roll her eyes or ridicule me to her friends. The next shift, when she saw we were still paired, she objected. “When will I be able to be on my own? I’ve worked in the ICU for four months.”
“You’ve never taken care of a patient with a chest tube,” I said, mentioning the very least of my concerns.
“I did once in the computer simulation lab at university.”
“But never a real patient,” I pointed out. What I wanted to add but wasn’t ready was a growing list of concerns: You didn’t reposition your patient for more than three hours until I told you to do so. You habitually leave your patients in soiled sheets, likely because you consider cleaning bums beneath a nurse with a university degree. You didn’t check your patient’s potassium level before giving him Digoxin* and you couldn’t tell me why your patient, who was in atrial fibrillation, was also on anticoagulation medication† Those were just three more damning indictments of her nursing care that sprang to mind. The rest of that day went well, but at the end of the shift, I told Tikki we needed to meet to discuss some of the problems I was seeing in her practice and that I planned to speak with our manager about it.
“Whatever,” she said with feigned disinterest. “But our little pow-wow will have to wait,” she added with a smirk. “I’m on vacation for two weeks. I’m off to Europe for the street music festivals.”
“Have a good time,” I said. “Let’s meet as soon as you get back.”
Meanwhile, there was a buzz in the ICU about Jenna. She had also been off work for more than a month. She wasn’t returning our calls and many of us were worried about her. I was more worried than the others because I knew the reason for her absence. She had called me and told me she was undergoing intensive treatment for infertility that required daily visits to the doctor and asked me to tell the others
that that was the reason she was off work. What she confided in me alone was that she was also off work due to emotional stress.
She was in trouble with the College of Nurses, our licensing body. A serious complaint had been lodged against her by the family of a patient she had cared for in the icu, more than a year ago. They had many charges against her, but it all added up to the accusation that Jenna’s actions had led to the death of their mother. I asked Jenna if she wanted to meet with me to talk things over and she eagerly agreed. I wanted to reach out to a colleague in trouble, but to be honest I also wanted to understand how this came about in order to make sure it never happened to me. If this nightmare could happen to a decent, competent nurse like Jenna, it could happen to any of us.
From what I knew of Jenna, it was impossible to imagine that she would do something purposely dangerous or harmful to a patient. It was also hard to believe that if she had made an error, such as Chandra had, that she would not have disclosed it. Had she actually made a mistake, I wondered, or was there a perception by the family of negligence? Indeed, if Jenna was being falsely accused, it’s a terrible experience but it is only a nurse’s second worst nightmare. The first worst nightmare is to be rightly accused. At any rate, I vowed to stay open-minded until I heard all the facts from Jenna and saw the documents of the case that she was prepared to show me. We set a date to meet.
I couldn’t help but think about some of the slips, the near misses, and mix-ups I’ve made or seen over the years. Fortunately, the vast majority of them have never caused any real harm and for me only served as useful prods to ever more attention and vigilance. But I don’t know a nurse who doesn’t have a war story or two.
In the privacy of our homes, many of us practise a rather macabre habit. As soon as we receive our bimonthly bulletin from the College of Nurses, we tear straight to its back pages to read the accounts of complaints lodged against nurses by members of the public, including the explicit details of their alleged – or sometimes proven – misdemeanours. The situations are painful to read, sobering, shocking, flabbergasting, embarrassing, and, occasionally, mildly amusing. Thankfully, they are very rare and I am not aware of any that have happened where I work. But still, we read those stories avidly. Maybe we do it out of curiosity or as self-imposed cautionary tales. It may even be schadenfreude, that guilty pleasure of enjoying someone else’s misery or its humble opposite: a dose of “there, but for the grace of God, go I.” Whatever it is, the accusations and verdicts meted out make for riveting reading. There is the one we still chuckle over, about the Director of Nursing whose nursing diploma and university degrees were discovered to be fraudulent. It seems that armed with fake academic transcripts, and forged references, she managed to convince a hospital that she held an Education degree, plus a Doctorate in Nursing Science. It turned out, she had only a lapsed RN certificate. But, “way to go,” we said, strictly in jest. You had to hand it to her – it takes some ingenuity to pull that off!