A Hard Lesson Learned

[VivaLasViejas, ASN, RN]

As we who have reached our middle years know, there are few things more satisfying than the realization that we have finally come into our own. It's not that we know everything, but we are wise enough to understand that we don't know everything......and to admit it. Every now and again, however, a situation comes along that shakes up our consciousness and blows our self-image right out of the water, and by the time the dust settles we realize---again---that we're not as 'together' as we thought.

Being an RN with almost a decade's experience under my belt, I like to think of myself as knowledgeable and mature, compassionate and competent. The other night, though, I was none of those things.........and a patient suffered because of it.

It was the 3 PM shift change, and in addition to my three stable pts, I was given a fresh post-op plus a very fragile patient at the end of one hall. That particular area tends to be a challenge, not only because those are the rooms which are the most physically removed from the nurse's station, but they are reserved for the sickest, neediest, most confused, and/or VIP patients. Everyone complains about this---after two or three shifts at that end, even the nurses who are in shape and very, very tolerant start to look a little ragged around the edges---but of course nothing ever changes, so we deal with it and then pray to be assigned elsewhere on our next shift.

As luck would have it, the very fragile patient had a husband who made Svengali look like a total wimp, and he'd alienated most of the staff already by being gruff, demanding, hypercritical, and just an all-around PITA. Sure enough, he started in on me right after the pt. got back from her CT scan; the radiology tech had just left her there in the room without hooking up the O2 or even plugging in the bed so the call light would work, and the husband was furious. I couldn't blame him, so I set about calming him down and going about the room straightening everything and hooking things back up. The pt. had a heparin drip, Procalamine, and lipids all going through a 22-gauge IV, and he wanted me to draw her PTTs through that because "they've already poked her too many times". He refused to consider allowing the doctors to put in a central line or PICC "because they're dangerous". He wouldn't even let me put in an additional 20-gauge saline lock!:angryfire

Then it REALLY hit the fan: the pt. started to retch, then vomited about 100 ml of blackish fluid which I knew was heme-positive even before the smell hit me. I'd heard nothing at all about this in report, so I assumed it was new and gave the MD a call. In the meantime, I was explaining everything I was doing to this man while I ran around giving medications to try to stop it, clean up the mess, and tell him once again why I was not going to draw the stat CBC from her IV line (of course, I'd stopped the heparin the instant she vomited).

While all this was going on, my TKR patient was crying and demanding a private room because her roommate had a visitor and they were being 'too noisy' (I could barely hear them on the other side of the curtain, but, well, you know). "I came to the hospital to sleep and rest(emphasis hers), and I have to listen to those women gab, gab, gab.......what sort of place IS this?!":uhoh3: Thank God my other three pts. were stable, because these two were a handful all by themselves (although to her credit, the Queen of the Total Knee calmed right down just as soon as her tantrum got her her way).

Unfortunately, the poor lady at the end of the hall continued to vomit that awful black stuff, and now her O2 sats were dropping and her BP was headed south as well. Meanwhile, I had call lights going off, phone calls from families wanting to know how their loved ones were doing, the pharmacy was wanting to know the entire med history of one patient I'd only had for an hour........and this bear of a man was griping to everyone within earshot about the 'incompetence' of every single staff member he'd encountered, how no one was taking proper care of his wife, yada yada yada. I tried to involve the department manager, who referred me to the nursing supervisor, who only told me to call the department manager, who finally said "We've already been in there, the man is an @zz****". No help there at all.

I went back into the room, and the patient was fading out........I called the MD again, only to be told her H&H were still OK and that we weren't going to move her to the ICU at this point. She still was vomiting, and now the husband was going nuclear at the idea of her not having 1:1 RN care: "What if she sucks that stuff into her lungs? She's got to have a nurse looking after her, I can't stay here all night, she HAS to be watched all the time", etc.

This is where I went wrong. I have never taken anything like this personally, but I'd had enough of this man's nastiness. I was doing everything I could, and nothing was good enough.........I sure as heck couldn't stand there and watch her, I had four other patients to care for, but he was having none of it. I was drowning, and so was my patient---yes, she aspirated, and two hours after I left for the day she was in the ICU on a ventilator.

Dammit, I made it personal, and I couldn't get anyone to listen because all that came out was "This patient's husband is driving me CRAZY!!" Yes, I told the doctor and the supervisor and the manager that she had an active GI bleed, but I wasn't focusing on the right person. Then on top of it, I failed to document anything but the calls to the physician---not the time I spent in the room, not the interventions with the spouse, only the calls and what I did with the orders. The one time in my career that I didn't document my hind end off.........oh, why did it have to be THIS patient?

So the next day I got called into the office for a dressing-down I won't forget anytime soon......and I have NO proof that I did anything more than give meds and call the physician. The man, not at all surprisingly, LIED---said that no one did more than "stick their head in once in a while" to check on her, and I can't prove that I spent probably 80% of those four hours in there.:uhoh21: :angryfire

I'm not going to spend the rest of my life beating myself up over this, but I do realize I should have handled this differently. I'm usually a very patient woman, but I let that pt's husband get under my skin, and as a result I didn't do all I should have to advocate for my patient and make sure she received the care she needed. As my manager pointed out, I should have gotten in the doctor's face, even the supervisor's face, and DEMANDED that she be moved to the ICU when I knew that was the place for her. When you get right down to where the cheese binds, all the excuses don't mean a hill of beans........that patient deserved better, and because I allowed myself to be distracted by her spouse's meanness rather than focusing on what SHE needed, she wound up in even direr straits than before.

This is why I'm beginning to really hate med/surg.....the patients are so sick now, the loads are just too much for me anymore. I can't keep up!! It isn't that I can't handle critical patients; just yesterday I worked ICU and had two extremely busy ones---both of whom were on insulin drips plus ETOH withdrawal protocol, and one was also on a Cardizem drip---and I managed just fine. Not many med/surg nurses where I work will even touch the drips, while I just plunge in there and work with them (and ASK when I don't know what to do!!).

But I'm still faced with the knowledge that I let that patient down........and it's not the fact that I may wind up as a co-defendant in a lawsuit down the road that really bothers me. It's realizing that I behaved in a most unprofessional manner, when I've always prided myself on my ability to read people well and handle the most difficult of them with grace. It's also knowing that I am fast reaching the end of my med/surg career and being far too young to retire; I won't give up nursing, but I do know that I'm unwilling to go back to LTC, and I don't want to do management again either. In fact, if I could just get a shot at it, I'd change to ICU in a New York minute......but where I work, they want only nurses who are already trained, or brand-new grads.

So yes, I'm feeling rather humbled these days, and I'm not sure yet what to do with this confusion, this unsettled-ness if you will. All I know is that no matter how long one remains in this profession, we never have it all down.......and that I still have a hell of a lot to learn.

[nurse4theplanet, RN]

thank you for posting this. I learned alot from your experience :icon_hug:

[dianah, ASN]

(((((((((((((( Marla ))))))))))))

I'm so sorry this all happened as it did. All I can say is, been there. Big hugs.

[Happy-ER-RN, RN]

I had a surprisingly similar situation just the other night involving an extremely confused (dementia) massive lower GI bleed. I spent the entire night trying to keep him in bed and scrubbing him from head to toe and changing all the sheets to get rid of the blood. I could not get anyone to sit with him because traumas were rolling in the door one after the next and everytime I turned my head he somehow smeared blood from head to toe. Then he started going down the s**ter and I couldn't get a Dr. to help me since they were all in with traumas. I have been looking back at the night and I feel so guilty, I should have been kinder and gentler with him (not that I was rough, but I could have been nicer), I should have advocated to get him some pain medicine since he was probably hurting even though he couldn't express it. I have never been so frazzled in my entire 5 months of nursing :) and in between Drs yelling at me in the trauma rooms and my confused pt. screaming non-stop I know that I was no longer capable of being the best nurse I can be.

It's easy to look back on a situation when you are calm and collected and not see how you could have acted a certain way, but when you have been beaten down over and over again for hours on end you just can not function the way you usually would. We have all been there. It is not your fault that she aspirated, things like that happen because we are overworked and understaffed--she should have gone to an ICU sooner but we all know how that goes. (you finally get the Dr. order and then well, there is only one ICU bed available but there is a dead person in it and the family is still in there....). We can only do our best with what we have to work with, we are not magicians.

Thanks for sharing your story, I learned a lot from it. When you are having a night like that you have to stop and take a look at what is really important.

[babynurselsa, RN]

wow Marla. These are always the ones. We never forget to document on teh quiet meek ones do we? I am sooooo sorry. How nice of the NM to back you up there too.

I hope this post relieved some of your stress. I agree with what you said about M/S they just keep getting sicker and sicker. While we are expected to do more and more.

Prayers for rest and brighter days.

[Tweety, BSN, RN]

I hate when a patient crashes and management armchair quarterbacks about "what you should have done". Nothing you would have done would have changed the fact that the patient would have aspirated and wound up on a ventilator. With all that was going on with your other patients I think you did a fantastic job with this patient.

That's the way med-surg is, you have to wait until a patient crashes and needs a ventilator before the patient is transfered. Your manager should have been more supportive (and I know you love your manager).

You did an excellent job by this patient. You called the doctor twice, you monitored her and she crashed. That's not bad nursing. People crash sometimes, don't own that.

I know my charting sucks on days like that too.

((((Marla)))))

[sjb2005]

After reading your post..it brought back all of those extremely challenging times I have encountered. Been there, done that...different circumstances. I have to remind myself, I am human, I have flaws, I am not the bionic and super nurse I am expected to be. I did the best I could and I think you did also. That is why I recently moved out of acute care. Way too much is expected of me. I won't let that buckle me. I have a mild burn-out because of the stress. And it doesn't help that I beat myself up either. I have never been written up or challenged by management. Only in my own perfectionist mind. Says alot about what medicine is expecting of us.

I deeply empathize with you. We have the ups and downs...that's why I cherish all the ups I can get. I have been a very valuable nurse to so many others. I am glad you posted. I am thinking of you.

[weetziebat]

Marla, I think you are beating yourself up waaayyyyy too much over this. Nurses are human beings, and no matter how much we want to be perfect, we're not. Who is?

You were facing this relative from h*ll, trying to care for a crumping patient, as well as the rest of your assignment, yet when you spoke with the supervisor and the manager - who knew what was going on - why didn't they do more to help you out? The hospital insists on placing patients they know need the most care at the other end of the hall, doctors don't listen, and its your fault for not insisting she be moved? Excuse me? Sounds like they're thinking 'the best defense is a good offense'. And can the relatives really call the shots like that -not allowing central lines cause they "are dangerous"!?! Do they get to O.K. every med as well? Gee, maybe they should have final say over which nurse cares for the patient! :angryfire

Yeah, you didn't document. That is a problem. For you. Cause we all know that if it isn't written it wasn't done. So you did nothing all shift. And no one stood up to say that was BS? Hon, you got absolutely no support either during nor after this awful incident - and you are blaming yourself.

Ugh! I am furious and I wasn't even involved. Sure makes me glad I got out of hospital nursing. No wonder nurses leave this profession.

So sorry this had to happen to you. You deserve better support at work.

{{{{{{Marla}}}}}} :kiss

[Thunderwolf, MSN, RN]

((((((((((((((((((((((((((((hugs)))))))))))))))))))))))))))))

[Gennaver, MSN]

As we who have reached our middle years know, there are few things more satisfying than the realization that we have finally come into our own. It's not that we know everything, but we are wise enough to understand that we don't know everything......and to admit it. Every now and again, however, a situation comes along that shakes up our consciousness and blows our self-image right out of the water, and by the time the dust settles we realize---again---that we're not as 'together' as we thought.

...

mjlrn97,

Oh, I feel like you got the shaft!

The system failed here, (the doc not listening, the hospital assigning the sickest to the furthest rooms and to top it off why didn't any other nurses help you out with this situation??)

Reads like you did the best you could with your very skilled and compassionate care. You are human. You had lots of odds against you. I am furious for you that anyone even tried to give you a talking to!! What? Why don't they give you a "LISTENING" to?

Rotten system mjlrn97, I hope you realize that you are not to blame for its errors.

Gen

p.s. why not try to change the system, (the rooms, the docs responses to an 'old' h&h versus what the nurse is signalling him to right there on the phone!) I hope you stop berating yourself soon

[DusktilDawn]

Let's see, you called the department manager, who then referred you to the who then referred you back to the department manager. The fact that you called these people should have been enought for them to realize that perhaps they should come to the unit and evaluate the situation. "We've already been there, the man is an @zz****" was the response, SHAME ON THEM. Irregardless of any patient's condition, if staff is dealing with an unreasonable family member or patient, IT COMPROMISES THE CARE of other patients on the unit and it needs to be addressed.

You manager then had the audacity to "dress you down" after leaving you high and dry and knowing that the spouse was diffucult. I can understand her talking to you about the documentation, but you know Marla, your biggest concern was dealing with the patient and irrate spouse, which you did as best you could under the circumstances without support, support which was refused because "the man is an @zz****." They obviously knew this person was difficult to deal with, they CHOSE NOT to deal with the situation and left it in your lap, irregardless of how that impacted your ability to provide adequate care. Oh and let's not forget the Queen of the Total Knee thrown in for added measure. The sickest, neediest, and most confused are placed the furthest away from the nurse's station, and despite staff complaints this continues. UUUUMMMMM, who isn't doing their job.....could it be THE MANAGER.

Also the MD you called based his assessment on the H&H, without actually seeing the patient. Want to bet he also didn't want to deal with the spouse.

Sorry Marla, you were left high and dry. How could this spouse not affect the care given to his wife in a negative way? Not only is he calling the shots, staff has to deal with his tantrums. You also had 4 other patients who required care. Rarely are we provided the support we need from our superiors. As Tweety put it, management armchair quarterbacks about "what you should have done." In your situation they ignored you, didn't set foot on the unit, then criticized you.

Sometime we just do the best that we can, and no it's not always good enough in this profession. And those are the times when we are the hardest on ourselves.

:icon_hug: :icon_hug: :icon_hug:

[UM Review RN, ASN, RN]

Yup. What they said. :yeahthat:

I also have to wonder if this whole scenario would've played out as described in the days before "customer service" became the key issue, instead of the focus being on giving quality care?