Advice

[PsychadellicNurse]

Hello all. I need some advice as I am struggling recently. It is important to know the whole story first. Sorry for the long read. 

About three years ago, I had my first medical issue with a patient. I was on the geriatric unit by myself with a nurse split between the geriatric and adult psychiatric unit. I had a full team of patients. One of my particular patients complained that she did not feel good that day and felt her COPD was acting up. She had a slew of medical issues such as A-fib, COPD, etc. She was a 78 year old that looked like she was 95. We took her morning vitals and everything was in normal range. I allowed her to stay in her room to rest instead of being up in the dayroom with the rest of the patients. We continued to check on her periodically, as we were supposed to. When it was time for her 11 am medication, I decided I would go back to her room and give her medication to her and obtain her vitals. My techs were busy getting patients up for lunch, so there was no reason to interrupt them when I could do it myself. Realizing I was running a little behind at noon, I went to the patients room and told her I had her Cardizem 60mg IR (two 30 mg tabs). She stated she still did not feel well and I reassured her that this medication would make her feel better. I had already checked her morning vitals and the previous shifts vitals, her vitals were consistent and ran about the same. I handed her the medication and began to take her blood pressure. She took the medication. Right after she took the medication, I heard the completion of the blood pressure machine reading and the alerting of an abnormal reading. I looked at the screen at it read 75/45. I immediately began to panic. I knew this couldn't be right as this patient was sitting and talking to me and displayed no symptoms of low blood pressure. I leaned out in the hallway and asked my tech to obtain a manual blood pressure cuff. When she arrived to the room, she informed me they had been using a child size cuff due to how small her arm was for an accurate reading. I attempted two times to get a manual blood pressure reading. I was for sure getting a bottom number reading of 58 but was not certain of a top number reading. I attempted multiple times but could not concentrate on getting a correct reading. I was still in panic mode thinking I had just gave this woman this medication with a blood pressure this low. I was too ashamed and scared to ask my tech standing there to obtain her blood pressure as I wasn't for sure what I was getting. So, I documented it was in range. At that point, I remember saying to myself you have two options. You can go ahead and call the doctor and tell him that her blood pressure is possible low or you could continue to monitor her and you would know if her blood pressure was low. I made the choice to watch her. The techs came into the room and helped her up for lunch. She ate a few bites off her tray but stated she did not feel like eating. About 30 minutes after the administering of the medication, I sat across from the room she was sitting at charting and observing her. I noticed her starting to nod in a sleepy manner. At that point, I decided to go ahead and call the physician. I decided if something was wrong with my patient, I didn't want to be the nurse that tried to hide something or not treat the patient. The techs obtained a current set of vitals, one manual and one automatic. They both registered the same 90/60 and a pulse of 70's. Her vitals were within normal limits. This had reassured me for a little. I still proceeded to call the hospitalist and inform him of her complaints of not feeling good and her current vitals. I informed him that I did give her the Cardizem about 30-45 before that. He said her blood pressure was still in range, but he would put in for some testing to assure everything was okay. He ordered an EKG, Xray, and bloodwork. We immediately obtained the EKG and I called him with the results. The only thing it read was a weak QRS, but otherwise normal. He informed me call him when transportation got there and he would meet the patient in xray to observe her. Within 30 minutes the ambulance arrived and I called the physician to inform him. After a short period of time, he called me back. He stated he observed her, listened to her, and she was denying anything was wrong. He assured me she sounded fine and he did not see any present issues. He informed me she would be returning to the unit momentarily but just continue to monitor her. She arrived back on the unit and was assisted back to her room. At this time, it was a little after 3pm and it was time for the techs to start obtaining evening vitals. I reminded the techs to use a smaller cuff on the patient, and if anything was abnormal to alert me immediately. They obtained her blood pressure around 315 and it was still within normal limits at 110/75 and pulse of 78 but stated the had a hard time getting a temperature on her axillary or orally along with an oxygen reading because her fingers were so cold. We placed the oxygen probe on her ear and obtained the reading of 94%. I informed the techs to get a temperature rectally. It was 97.1. I knew this was lower so I immediately called the physician. I informed him of her current rectal temperature and vital signs. He informed me to transfer he to the medical floor as she was "not stable" enough to be placed on our unit. I immediately called nursing supervision and called an ambulance for transportation. Around 345 pm the charge nurse on the other unit came over to inform me of staffing when the techs, who were still obtaining vitals, was beside the patient's room and yelled for help. The stated she had just slumped over in the bed unconscious. Both the charge nurse and I ran back to her room, and he began to try and stimulate her. I immediately ran back up to the nurses station and called the physician. The techs had brought me a reading of her current vitals which had plummeted. Her oxygen was at 78%, her blood pressure had plummeted, and her pulse was weak and thready. He informed me to get an ambulance there immediately to send her to the ER but continue to use the ambubag on her until they arrived to keep her oxygen up. I immediately called the ambulance back and informed them we needed an ambulance stat as she was unresponsive. They arrived within the next 10 minutes and took her to the emergency room. The physician called me about 530 from the ER and informed me that it did not look good. He was assuming at the time it was a calcium channel blocker/ beta blocker overdose but was not certain. They put her in ICU and she passed away a week later.

At that point, I wondered if that medication I gave could have caused this in anyway?  Over the next four days I put myself through hell. I debated on turning in my license and resigning as I had convinced myself what had happened was because of me. A few days later I went and spoke with my manager and informed her that I would be resigning and that I felt it was my fault.  I had informed her that I was not for sure if the vitals I entered in when I gave her the 11am medicine was correct. My manager told me that was not plausible, that even if her vitals were abnormal, this medication would have not caused what happened. She informed me after reading through the chart, the physician suspected a pulmonary embolism to be the cause. Still, in my mind, this wasn't definite. She reassured me to learn from this event and use what I learned to treat future patients. 

Over the next few months, I began to see therapist, psychiatrist, and talk to pretty much every medical person I could. They all reassured me that my thought process was not plausible. All of the medical staff I talked to almost immediately informed me that it sounded like a pulmonary embolism after I told them the sign and symptoms. 

So here I am three years later. For two and a half years I have been great until I recently had a miscarriage from my first pregnancy. So I was taken off all my medications (antidepressant and anxiety meds. This miscarriage happened to be on the day before the three-year anniversary of this. I felt in some way this is me being punished. I guess this triggered a trauma response (because this was the first death since this patient) because a thought process came up that I had never even thought of before. What if I gave the wrong medication?

In a way I know that this may seem farfetched to some that are experienced, but I have only worked in psych my whole career. The crazy part of all this is that I remember pulling this med from the pyxis (the cubbies that don't have the lid), and I know that I am diligent in checking and double-checking medications. My mind is just freaking out because I don't remember scanning the medication. Yes, I understand that I am not going to remember everything about that day from three years ago, but it is like I cannot logically process. I know I say to myself also if it was a wrong medication there would have been indications 1) before a four-hour period and 2) she wouldn't have had stable vitals because lord knows I was watching her like a hawk after the first fax pas. 

It's just crazy because this has hit me out of nowhere again. 

 

[JBMmom, MSN, NP]

It sounds like other than charting vitals that you weren't 100% sure of, or worse- knew were inaccurate- you didn't do anything wrong. 

The patient had periods of stability based on her vital signs between the time you administered the medication and when she transferred out. Yes, medications take some time to work so it wouldn't have reached peak activity level until a bit later, but for lack of a better explanation, sometimes things just happen. There are people that very often feel the "impending doom" but have nothing that's visible or even can be charted on in a tangible way. You can't send everyone that "doesn't feel well", to the hospital. You made everyone aware, I might have informed the doctor a little earlier and not decided to monitor, but that's not the cause of her demise. 

Many of us have had patient experiences, including deaths, that stick with us throughout our careers. Sometimes these experiences bleed over into the rest of our lives and your anxiety sounds like it might be in part related to this. You can't change what happened to that patient, but it's HIGHLY unlikely that you did anything to directly contribute to this patient's death. You've just experienced a traumatic loss yourself (I'm sorry about your miscarriage), but you are in NO WAY being punished for this, just an awful coincidence. Be kind to yourself, you're doing your best. I wish you all the best with your professional, personal, and parenting journeys ahead. 

[Davey Do]

PsychadellicNurse, I will focus on your final statement, "this has hit me out of nowhere again".

The most important thing we can do about a traumatic past event is gain a new perspective on it in order to heal and grow. We cannot change what occurred, we can only change our feelings about how we feel about ourselves and the situation.

There's a truism that says we all do the very best we can in any given circumstance at any time. We all have 20/20 hindsight, see how we could have done things differently, and can be our own worst critics and faultfinders. We are human and subject to fallibility, make mistakes & misjudgments and sometimes there's no way around it.

If we cannot forgive ourselves for any possible wrongs done, whether inadvertently or not, we will carry that baggage with us forever. That baggage will weigh us down and come back to haunt us, as in your case of being hit out of nowhere again.

Forgiveness is a cyclical process, in that we need to practice it every day, sometimes several times a day. If we forgive another who has wronged us, thoughts of retaliation or revenge sometimes later creep in, and we must forgive that person all over again.

The same is true in forgiving ourselves. We can say, "Okay, I'm human, I made a mistake, and I must forgive myself". That initial forgiveness does not mean it's all over and done with, wrapped up nice and neat in a package, because our minds will revisit the feelings of guilt. We may need to routinely practice forgiveness for years before our negative feelings about ourselves wane down and no longer affect us.

I speak from experience from a situation not unlike yours.

Forgive yourself and get closure, PsychedellicNurse. It is the healthiest thing you can do for yourself.

The very best to you.

[Been there,done that, ASN, RN]

The miscarriage most likely triggered your anxiety over that event. I hope you are able to continue your psych meds and your therapy.  I see that you remember every detail about that event, three years later. That makes me think you have been beating yourself up frequently over it.

You were appropriate with your care. She was a  very sick 78 year old .... and it was her time to go. You just happened to be around.

 Peace.. I hope you can let this go. Three years is plenty long enough to suffer over it.

 

 

[PsychadellicNurse]

2 hours ago, JBMmom said:

It sounds like other than charting vitals that you weren't 100% sure of, or worse- knew were inaccurate- you didn't do anything wrong. 

The patient had periods of stability based on her vital signs between the time you administered the medication and when she transferred out. Yes, medications take some time to work so it wouldn't have reached peak activity level until a bit later, but for lack of a better explanation, sometimes things just happen. There are people that very often feel the "impending doom" but have nothing that's visible or even can be charted on in a tangible way. You can't send everyone that "doesn't feel well", to the hospital. You made everyone aware, I might have informed the doctor a little earlier and not decided to monitor, but that's not the cause of her demise. 

Many of us have had patient experiences, including deaths, that stick with us throughout our careers. Sometimes these experiences bleed over into the rest of our lives and your anxiety sounds like it might be in part related to this. You can't change what happened to that patient, but it's HIGHLY unlikely that you did anything to directly contribute to this patient's death. You've just experienced a traumatic loss yourself (I'm sorry about your miscarriage), but you are in NO WAY being punished for this, just an awful coincidence. Be kind to yourself, you're doing your best. I wish you all the best with your professional, personal, and parenting journeys ahead. 

JBMmom, thank you for the kind words. Yes, since this was the first time I have ever delt with this and by myself, I freaked. The charting I could not undo because then it would take away the medication administration. It is funny though that you talk about impending doom because I remember the niece saying that she had told them going into the hospital that she would not make it out. Thanks ?

[PsychadellicNurse]

1 hour ago, Been there,done that said:

The miscarriage most likely triggered your anxiety over that event. I hope you are able to continue your psych meds and your therapy.  I see that you remember every detail about that event, three years later. That makes me think you have been beating yourself up frequently over it.

You were appropriate with your care. She was a  very sick 78 year old .... and it was her time to go. You just happened to be around.

 Peace.. I hope you can let this go. Three years is plenty long enough to suffer over it.

 

 

Been there:

Thank you for the kind words. I only remember this so vividly because I actually had this in my journal from before, otherwise I would not remember these details. Trust me when I say I don't want to suffer, but instead know that I did the best I could. 

 

[vintagegal, BSN, DNP, RN, NP]

As a hospice nurse, I will say that people start passing before they start passing. Fluctuations in LOC and vitals is very common. People start to feel their body changing long before we start seeing clinical signs. One of the things I ask my patients is “do you feel yourself changing? Do you feel unwell? Do you feel as though it is your time to go?” This opens a dialogue and believe it or not patients will actually share what is happening with you in regards to their body. It sounds like this woman was chronically Ill and was dying. There is often times no “smoking gun” cause for death, it is a domino effect of several organ systems shutting down.

don’t beat yourself up. Just always take the vitals before the bp meds. That would have saved you a lot of stress and anxiety.