Desparate, freaking out

  1. Yesterday I triaged from 7-3 dayshift in our 17 bed ER. It was extremely busy, as usual lately. We kept a full ER and a waiting to come back list of 10-20 patients all day. Today my supervisor called me to let me know that apparently someone that I triaged for low back pain and nausea and vomiting for 2 weeks , a middle aged gentleman, and marked non-urgent coded in the waiting area after I left.
    Ever since that phone call this am I have been a nervous wreck. I trust my triage skills, although I triaged so many people yesterday that I honestly cannot remember this particular patient at all. I know if I had seen or heard something on exam and interview I would have brought him straight back, even if I would have had to placed him in the hallway, which already had patients in it. A little bit ago the hospital left a message on my machine to meet with hospital lawyers on Thursday.
    I am completely freaking out. What if I missed something,
    will I ever be able to triage again without being scared of missing something? I realize we can't have a crystal ball to look in to see who has death lurking over their shoulder, but I still feel awful. Has this ever happened to anyone else? How do you go on without constantly second guessing yourself? Any respones will greatly be appreciated, as I am currently breaking out in one giant zit and getting a giant migraine from the stress. :stone
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  2. 30 Comments

  3. by   sunnygirl272
    do you have malpractice insurance?
    and remember that the hospital's lawyers are exactly that: the hospital's lawyers....they don't give a flying hoo-haa about YOU...they will act like they do...but you are not their client...the hospital is...
  4. by   emmRN
    I had a patient once that I found dead. I had a lot going on with two other patients that shift (resp distress, transfusion reaction, etc). This guy was in for pain control and was waiting to go to dialysis later that morning. Nothing going on to indicate he was on death's door. I freaked. I thought it was my fault, should have checked on him more often, my initial assessment wasn't thorough and I missed something, thought I might get fired or lose my license, and so on and so on.
    Nothing came of it. My boss settled some of my fears with a heart to heart talk. These things happen. Like you said, we have no crystal ball. We do our best, what more do we have to offer? I watched my patients much more closely for a long time, but I've regained my confidence in my skills. You will too.
  5. by   Nurse Ratched
    Ditto what Sunnygirl said. Let me say that I admire the hell out of you working that position - there is so much going on and it's probably a miracle more things like that don't happen. You're asking yourself "what if" and "what could I have done differently" - those are good things to ask. Reviewing these things in our minds is part of what makes us grow professionally. And it's entirely possible that nothing was done "wrong" - that is, you went with the information you had and made a reasonable judgement call based on that info and someone just went bad. If you have no recollection of this particular patient, I would just refer to whatever documentation you made at the time. Don't let the lawyers railroad you into saying something that will get twisted around later.

    Good luck - I'm sure you're upset; we are here to lean on.
  6. by   Dr. Kate
    My gut feeling is you didn't miss anything. I'm not an ER nurse, but with a 2 week history of vague, flu like symptoms you were not looking at an acute cardiac event in the triage room. Or even, a delayed event. You know as well as I do, it's called sudden death, beacuse there was no warning.

    I think it is to your advantage that they want you to talk with the hospital lawyers this early. For one thing, the events of the day are still pretty clear in your memory.

    It sounds as if they family has made noises about suing because the fellow died and the hospital is being self-protective in getting information early. Remember, anyone can sue for any reason. I think this will protect everyone far more than waiting a couple years and then calling you in to discuss the day.
    Read what you wrote, be honest about what you recall and don't make anything up.

    Personally, I have great faith in your nursing assessment abilities because you are so very concerned. Because you know you would not have been casual about a cardiac event. Because you are trying to figure what you missed, what you should have seen to know this was coming, what more you could have done. Really good nurses reflect on their practice, review what they did, evaluate it, and learn from it. You're doing just that. The unfortuate thing is that the really good nurses are so very hard on themselves when they miss something. Good nurses don't take it well when they find they're not perfect, they jump to the conclusion they're no good, when they really are very good, just not perfect.
    How do you go on? Well, you get back in triage and you take it a bit slower for a few patients, you realize you're still good at triage, it gets busier and busier, if you get time to think about it you realize you are looking and listening a bit more carefully. Then, on someone you'll catch the subtle signs of something more going on, you'll intervene and be right. You will start to believe you not only can do this but are good at it.

    Do some nice things for yourself. Try to be a bit gentler with yourself. Many hugs.
  7. by   llg
    Not all hospital lawyers are bad guys. I was not named in a suit, but peripherally involved as the case played out over a period of 3 years (actually going to trial 3 times). Our hospital lawyers were terrific the whole time to all of the nurses involved. Don't assume they are evil just because they work for the hospital.

    Listen to what they have to say ... and as someone else said, don't say or sign anything you are uncomfortable with. Check out the situation thoroughly before you jump to any conclusions -- just as you hope the hospital and the lawyers will.

    llg (who also carries her own insurance, just in case.)
  8. by   Sleepyeyes
    Originally posted by Dr. Kate
    My gut feeling is you didn't miss anything. I'm not an ER nurse, but with a 2 week history of vague, flu like symptoms you were not looking at an acute cardiac event in the triage room. Or even, a delayed event. You know as well as I do, it's called sudden death, beacuse there was no warning.

    I think it is to your advantage that they want you to talk with the hospital lawyers this early. For one thing, the events of the day are still pretty clear in your memory.

    It sounds as if they family has made noises about suing because the fellow died and the hospital is being self-protective in getting information early. Remember, anyone can sue for any reason. I think this will protect everyone far more than waiting a couple years and then calling you in to discuss the day.
    Read what you wrote, be honest about what you recall and don't make anything up.

    Personally, I have great faith in your nursing assessment abilities because you are so very concerned. Because you know you would not have been casual about a cardiac event. Because you are trying to figure what you missed, what you should have seen to know this was coming, what more you could have done. Really good nurses reflect on their practice, review what they did, evaluate it, and learn from it. You're doing just that. The unfortuate thing is that the really good nurses are so very hard on themselves when they miss something. Good nurses don't take it well when they find they're not perfect, they jump to the conclusion they're no good, when they really are very good, just not perfect.
    How do you go on? Well, you get back in triage and you take it a bit slower for a few patients, you realize you're still good at triage, it gets busier and busier, if you get time to think about it you realize you are looking and listening a bit more carefully. Then, on someone you'll catch the subtle signs of something more going on, you'll intervene and be right. You will start to believe you not only can do this but are good at it.

    Do some nice things for yourself. Try to be a bit gentler with yourself. Many hugs.
    For some reason, Dr. Kate, I found myself in tears as I read your response. Thank you. I guess there are a bunch of us who needed to hear that.
  9. by   Tweety
    I agree you did the best you could do and probably any nurse would have done the same thing. That if someone has had these symptoms for TWO WEEKS, it wouldn't be deemed urgent. Continue to trust your instincts. Our society loves to lay blame, especially in unexpected death. Unless you walked up to him and killed him, YOU DIDN'T KILL HIM.

    Dr. Kate, great post.
  10. by   cargal
    For some reason, Dr. Kate, I found myself in tears as I read your response. Thank you. I guess there are a bunch of us who needed to hear that.

    That needed to be posted again. Thanks to both of you.
  11. by   l.rae
    ah defib queen, l can feel your pain....as a fellow er nurse who btw hates triage, for the very reason you relate above. based on the hx you give above l would have made same call. low back pain, n&vx2wks...gee, sure doesn't sound life threatening. l've always heard the legal judgement is based on what a reasonable response would be by other similarly trained nurses....when you talk with your supervisor, note his history and anything else. so far, sounds like l would have made same judgement...good luck....LR
  12. by   ratchit
    With perfect 20/20 hindsight, it sounds like a dissecting AAA to me. But that picture doesn't quite fit- 2 weeks is kinda long, the patient was kinda young, and I didn't see anything about the classic "tearing" sensation. Just a gut feeling with a lot more info than you had at the time.

    It was probably a stoic guy who was hounded into going to the ER and underplayed his symptoms because he didn't want to be there. If you do ER triage, you have an excellent "gut" sense for doom. But if someone doesn't have something overtly wrong and tells you they have flu symptoms in January, I don't see any reason to have treated it as anything else.

    You heard hooves, the patient described horses. No reason to beat yourself up over being surprised by a zebra.

    Have a glass of wine, ask the man for posthumous forgiveness, and forgive yourself. Good luck.
  13. by   sunnygirl272
    Originally posted by ratchit

    It was probably a stoic guy who was hounded into going to the ER and underplayed his symptoms because he didn't want to be there. If you do ER triage, you have an excellent "gut" sense for doom. But if someone doesn't have something overtly wrong and tells you they have flu symptoms in January, I don't see any reason to have treated it as anything else.

    You heard hooves, the patient described horses. No reason to beat yourself up over being surprised by a zebra.

    Have a glass of wine, ask the man for posthumous forgiveness, and forgive yourself. Good luck.
    well said!!!
  14. by   ?burntout
    i am not an er nurse, but like it has been said, we don't have x-ray vision........besides.....he had been hurting for 2 weeks?!

    just go by your notes........:kiss ....((((hugs))))

    p.s. thank you dr. kate!!!!!!!

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