+A perfect storm of errors in ER.

[Kitiger, RN]

My Mom almost died in a perfect storm of errors in ER. This is a letter that I later wrote to her pulmonologist.

I'd like your help in reporting an incident involving my Mother that occurred in ER on {date). As you know, she died the following day of respiratory failure brought on by Post Polio.

The ER doctor had ordered Dilaudid 2 mg IV push before the CT scan of her lungs, to decrease the pain of lying on her back. I had told the doctor that - as a Post Polio - Mom wouldn't do well with that high of a dose, but he didn't listen to me.

Beginning right after she received the Dilaudid, she was asleep and barely arousable, although her respiratory effort looked like her usual while asleep. She dropped gradually from 95% to 78% on 100% oxygen using a non-rebreather mask. That was before the CT scan, and the nurse knew it.

I didn't yet realize that Mom was dying, although I was on her side when she said she didn't want CPR or a vent.

There were several problems while she was in ER; I won't go into them here. The problem I want to address involved the non-rebreather mask. A nurse took her to have the CT scan of her lungs. She was hooked up to an E-tank for transport. However, when she returned to ER, the oxygen was not reconnected to the wall. As you know, an E-tank will not last very long while set at 10 to 15 liters/minute. My guess is that it would last maybe 10 to 15 minutes?

I didn't catch it at first. All at once, I noticed her SpO2 starting to drop. 76%, 73, 71. I turned her call light on. 68. 66. I ran out into the hall, but didn't see anyone close by. 58. 55. I finally saw that the reservoir to the non-rebreather mask was becoming flaccid. Frantically, I followed the tubing to the empty tank, and reconnected it to the wall.

Her SpO2 stayed at 50%.

I ran out into the hall again, found two people talking, and told them that my Mom's SpO2 was only 50! They came right in. By that time, she read 61%, 65%, and gradually back to 78%.

Mom could have died right then. Someone else could die from a similar error. I don't want to raise a stink here, but this is a problem that needs to be addressed. Please consider this as an incident report.

There are several things that went wrong. The ER was short-staffed. The alarms on the pulse oximeter had been disabled. Perhaps this was because there was no way to set the low O2 alarm below 78%?

The transport person was right to refuse to transport Mom; her status was too unstable. But perhaps the nurse who did accompany her was not used to the routine of making sure the oxygen was reconnected to the wall.

Is it a normal routine to make sure the oxygen is reconnected to the wall? It should be.

[nortonplusRN]

I'm sorry for your loss.

[canoehead, BSN, RN]

I've found that error on my patients too. I was in the trauma room and someone sent my patient to Xray. They were transported back and not reconnected to wall oxygen. With all the beeps and alarms in place, you would think that an empty O2 tank would have an alarm as well.

[Kitiger, RN]

I'm sorry for your loss.

Thank you.

I've been thinking about Mom a lot lately. It's been 13 years, and I still kick myself that I didn't realize that she was suffocating. My consolation is that she was snowed at the time, and she probably would have died that week anyway. (I had found her unresponsive 3 days earlier because her oxygen had come off. She regained consciousness when I replaced the oxygen.)

[Kitiger, RN]

I've found that error on my patients too. I was in the trauma room and someone sent my patient to Xray. They were transported back and not reconnected to wall oxygen. With all the beeps and alarms in place, you would think that an empty O2 tank would have an alarm as well.

That is why I wrote that letter to her pulmonologist; I didn't want it to happen to anyone else. Her pulmonologist was the one who taught the pulmonology classes for the ER nurses.

[Here.I.Stand, BSN, RN]

I'm so sorry for your loss!

[NickiLaughs, ADN, BSN, RN]

I'm sorry this happened to you and I'm sorry you lost her after what seems some questionable judgement calls.

[blondy2061h, MSN, RN]

I'm sorry for your loss. I imagine your mom went through a lot as a polio survivor. I see she was a DNR/DNI. Would she have been okay with bipap? I wonder if that would have been more helpful. Was she on any sort of respiratory assist device normally while sleeping (or around the clock)?

I'm curious what ended up happening as a result of your letter.

[Kitiger, RN]

I'm sorry for your loss. I imagine your mom went through a lot as a polio survivor. I see she was a DNR/DNI. Would she have been okay with bipap? I wonder if that would have been more helpful. Was she on any sort of respiratory assist device normally while sleeping (or around the clock)?

I'm curious what ended up happening as a result of your letter.

Mom had had an abnormal sleep study earlier that year, but she had refused BiPAP. She said she would not be able to handle the mask and tubing, and I believed her. She could barely lift her arms to eat at that point.

She had come into ER to get the fluid off her lungs. She had been in right-sided heart failure for years, and now appeared to be in CHF. (She had had an episode three days earlier where she was unresponsive after her oxygen fell off. She came to and was fully alert after I found her and replaced the oxygen. That episode probably further damaged her heart.) Her cardiologist had told her she could come in through ER, and they would give her IV Lasix and a foley. Instead, the ER doctor insisted on a CT scan to rule out pulmonary embolism!

After the CT fiasco, he ordered BiPAP. When she woke up from the Dilaudid, she found herself in bed, unable to move because she was lying down, unable to hear (she was almost deaf, and they wouldn't let her have her hearing aide.) She could read lips, but couldn't talk well with the BiPAP mask on. The ER doctor tried to get her to agree to a sedative and a trip to ICU. NO! She didn't want that, because they would intubate her and she would probably never be able to wean off the vent. Did I mention that she was a nurse? She knew what she was talking about.

I tried to talk to the ER doctor, but he told me that I had no right to decide for her. (True, the Durable Medical Power of Attorney would only go into effect if she was unable to direct her care, not if she was merely under the effects of Dilaudid.) I wasn't trying to decide for her; I was trying to get him to listen to her!

I had called her pulmonologist, and one or her partners called over, and ordered "No sedatives until one of them could come and talk to her." When he arrived, he confirmed with her that she didn't want BiPAP or a vent. Not ever. He pulled me out to the hall and confirmed that I knew that she was dying. Her urine output had stopped, and she was not able to maintain adequate oxygen saturation without at least BiPAP. I knew. It was hard, but my goal had always been to help her make her own choices.

He stopped all the critical interventions and ordered oxygen per NC, as she had used that for years. And he ordered morphine for distress.

She died the next day, but not before family had a chance to come in and see her while she was lucid and able to talk. She died peacefully.

Her pulmonologist called me at home after she got my letter. She asked if she could use my letter in the classes she taught to the ER nurses. She would remove mom's name, etc. I said yes. I also asked her to talk to the ER doc, and she said she most certainly would! I never followed up with her. Mom had trusted her. I trusted her, and I knew she wanted to try to prevent something like this from happening again.