Murphy's Law Experienced

luvRNs, BSN, MSN, RN

Kinetic energy carried me forward into the saddlehorn, and I suffered an open book fracture of my pelvis. My horse, alarmed at falling behind the others, began to gallop again. I decided it was time to bail off, and tried to control my fall to the ground.

Shortly, the others returned when a riderless horse caught up to them. I informed them of my injury, 911 was called, and help sent. Then the anxiety and lack of control set in. I was loaded into a rescue and brought to the local trauma center. So far, so good....

I was fortunate to receive good pain management, but found that I urgently needed to relieve myself thanks to my fluid resuscitation. A nurse came in and offered a bedpan. I refused, saying there was no way I could tolerate being placed on a bedpan and asked for a foley. Those of you who are TNCC trained know that this is a 'no-no'. Pelvic fracture can be accompanied by a torn urethra, and foleys are not inserted until a urethral or bladder tear can be ruled out. The nurse placed the foley, caving to my pressure. Outside my cubicle door I heard the physician berating the nurse. Lesson # 1; do what's indicated, even if it angers the patient.

I was sent to the floor shortly after, and scheduled for surgery on Sunday. On week-ends normal procedures were MODIFIED. Pre-operative patient were brought to recovery rather than put in a preop holding area. Several of us were lined up on stretchers waiting. A nurse came over to me, called me by the wrong name, and told me they would be coming to start my knee surgery. I corrected her and she walked away. After several minutes, she again retured. Once again she identified me by the wrong name and surgery. I became agitated and requested the staff return me to my room until they could properly identify my name, MD, and planned surgery. The lessons here were myriad. First, routine IS a safety mechanism. Whenever a procedure is modified it expose risk for error. This is taught by Crew Resource Management programs. Second, best practices such as marking the site, and confirming personal identifiers protect all involved from the patient to the staff. They are a necessary safety practice.

Thankfully, the rest of this hosiptal staff proved uneventful. Two days after discharge, I rolled over in bed, felt a clunk and was thrust into severe pain. My internal fixator had broken. Back to inpatient status I went, this time for both an internal fixator, but for an external fixator as well. The surgery was performed, and I awoke to my loving husbands face. I dozed for much of the evening, awakening only to say good night to my husband when he left. I woke again around midnight to find my nurse irrigating my foley. The nurse in me kicked into higfh gear. What's my urine output? None for two hours. What are my vital signs? Fine, not hypotensive or tachycardic. What is my hemovac putting out ? 300 cc bloody an hour. WOW....how fast is my IV? What is my hemoglobin and hematocrit? OK. She left. Frightened, I struggled to stay awake. I kept feeling my pulse, checking my IV, and checking my foley and hemovac. My urine output was scant, and my hemovac still filled quickly. despite me best intentions, I does again, only to be awaked by a concerned RN irrigating my foley once again. I still had no urine output? Very little. She left and I stayed awake. After an hour, I noticed a significant change, my hemovac contents changed from sanguinous to reddish-yellow. As a ICU nurse, I put the pieces together. My bladder had been perforated, and my urine was draining out the hemovac. The nurse returned to the room. When I informed her of my suspicions, she freaked, and asked ME what she should do. I told her that bladders were often left to heal by secondary intention in order to lessen scarring. Urine is sterile, and therefore a leak into my pelvis was not exposing me to the risk of sepsis.

The long night ended and morning FINALLY came. With the daylight came my husband. I cried on seeing him, and felt I could FINALLY go to sleep, as someone would watch over me. Moring also brought the doctor, and emergency testing. My suspicions were correct. My bladder had indeed been perforated.

That night was the best and worst night of my life. Horrible to experience, it was transformational to my nursing care. I vowed to never again become complacent. What is routine to us is NOT to others. It is a very individual experience. Seemingly dumb requirements, like checking ID and adherence to routines are truly safety measures that should NEVER be compromised. Listen to your patients. You will be surprised at what you may learn. Hospitals are NOT safe places to be. Any and all systems can fail patients. Errors are rarely staff-caused, they are system-caused. As health care professionals it is our job to identify threats to safety and to advocate for related enhancements. Both your patients health and your liability depend on it.

Finally, there is one safety enhancement that can not be denied. It is receiving well-deserved attention recently. It is called family-centered care. Caring family are a patient's first safety net. The know the patient, thus quickly spot subtle changes. They care for the patient, and thus advocate for the patient who can't speak for themselves. Appropriately-guided, they can assist the nurse in providing basic needs. They are a PARTNER in care,and we need to collaborate with them as such. New hospitals are designed with this concept of family in mind. Will there continue to be abusive, and disruptive families? Of course. Life is not perfect. I for one celebrate the change for what it is. Safety for all of us.

Murphy's Law Experienced

About luvRNs, BSN, MSN, RN

More Like This