Feeling guilty ALL the time

You know how some people will learn from their mistakes objectively, figure out how to avoid making the mistake again, and move on?

I work in a Level I trauma center as an ER nurse. I constantly beat myself up over things that may or may not be in my control. An example from the other night:

1. I was the bedside trauma nurse during a busy shift. Traumas were coming in from the start at 1900. My other three patients were: A. Patient with high fever and hx of cellulitis of the leg. Diabetic and on a self-administering insulin pump. B. Patient who willingly came in for EToH detox, currently asymptomatic, vital signs stable. No other complaints. C. Immunocompromised patient with high fevers and suspected PICC line infection, vomiting, and suspected rxn to his Vanc that was running. I chose to see patient C first, assessed his airway d/t the suspected rxn (all was clear), administered an antiemetic to control his vomiting and an antipyretic to lower his fever. I quickly eyeballed the other 2 patients and then left to attend to a new patient in the trauma bay, and I asked a floating nurse to watch my patients. After the trauma, I came back to find that patient A's blood glucose was 45 and had to be treated with D50.

I felt awful because somehow I felt like I should have been the one to catch the blood sugar. I felt deficient as a nurse for not being the one to check on the patient and noticing symptoms of hypoglycemia first. The patient's blood sugar came up to 70, and then I started the ordered D5W infusion at 125/hr. The patient's status quickly improved thereafter.

Furthermore, I noticed that patient C was becoming more and more lethargic throughout my shift. He was febrile at 102, so I administered IV Tylenol as ordered by MD. I checked his blood glucose, 124mg/dL. I assessed his orientation, he was arousable to verbal stimulus and answered orientation questions appropriately. He maintained his pressures at around 120 systolic, and his heart rate/rhythm was stable. O2 was around 93-97%. I made our ER doctor aware of the patient's increasing lethargy, and he said this may be expected because of strong suspicion of sepsis. I also made the patient's admitting team aware via page. And finally during report to the stepdown unit RN, I made sure to tell her that I noticed the pt was increasingly lethargic. She accepted the report and another nurse in the ER transported the patient to the unit for me. Maybe just 10 minutes after she transferred the patient, I hear the overhead system paging an RRT to his room in stepdown. I later found out that the patient had to be transferred to ICU level of care. I found out that once there, his pressures were 70s systolic and he was arousable only to sternal rubbing.

I felt so overwhelmingly terrible. I know I'm responsible for my patient, I just want to know what I could have done differently. During my assessment the patient was arousable to verbal stimulus. Our vitals in the ED have to be updated within an hour before transfer to any floor, and they were all WNL.

AllNurses community, please tell me what I could have done differently to avoid this issue. The amount of guilt I feel is haunting me. It's haunting me because I care so much about my patients, they cannot fend for themselves and depend on me for astute assessment and advocating for their safety.

Please.

I'm not even going to attempt to address the medical issues. ER is not my area of expertise. Here's my take on the whole thing: Learn to be kinder to yourself. If things are out of your control, you cannot control them. If you're constantly beating yourself up, you're constantly under a great deal of stress. Be kind to yourself, let the stress levels abate and you will probably find that you learn more easily -- from your mistakes, the mistakes of others, from reading, from seminars, etc.

Guilt, anxiety and stress are not conducive to learning but they sure hasten burn out. So does caring too much. Yes, patients are vulnerable but nursing is a job, not a calling.

Take some time after work, before work and/or on your days off to do what nourishes your soul. Go to church, walk in the woods, write in a journal, play with your dog -- whatever makes YOU calmer. Take care of YOU first. You are worth it.

Ruby Vee, I cannot say thank you enough for your kind and helpful insight. I guess sometimes I do lose sight of the fact that my stress will not lead me to learning but will lead me to hastened burnout, as you say. I will take your advice and engage more in activities that make my soul feel better. Thank you again...

You don't drive the medical care, that's the provider's job. So I don't think you did anything wrong. You did have another nurse cover in case anything changed, and guess what, it did. The patient was treated appropriately. You notified the provider about a change in mental status which puts it on them to investigate. The MD's remark that a change in mental status is to be expected seems a bit blasé. Altered mental status in the face of shock is deadly serious and needs to be addressed immediately. If not, the patient could decompensate. Oh wait, that's exactly what happened (not your fault). What you could have done differently perhaps, is to more assertively remind the MD that the patient was deteriorating. What is not here is the dynamic between you, the MD, their experience, the culture of your department and so on. This all affects how things go. I work in a small ER, we all know each other, no students, and the MD's take our concerns seriously. Take a breath. Patients will have bad outcomes sometimes even if you do everything perfectly. You can't take it personally. You did everything that nurses are expected to do. Hope this helps.

You did everything right, don't be hard on yourself when your patient crashes. You are not the provider either so don't try and run the show either its just a matter of watching out for your patient and do what you were trained. Sounds like you did exactly what you were trained to do.

In my opinion, it sounds like inadequate staffing (or some other organizational issue) played a big part in the negative patient outcomes, not a lack of skill or caring on your part. One of the ways we can advocate for our patients is by advocating for ourselves. What resources are available to you when you need help? Did the nurse watching your patients have their own assignment as well? Do you get full coverage for your lunch and rest breaks (not a nurse with their own assignment watching your patients) so you can stay at the top of your game? The patients in your assignment already were pretty sick, needed frequent reassments, and had the potential to decline. Is it reasonable for them to expect you to take trauma patients with that assignment? I suggest talking to your leadership. Maybe they will actually be responsive and you can come up with a way to prevent situations like this from happening again. I know getting more staff and changing hospital policy and culture is hard, and that not everyone is willing to listen, but it's not right if you were made to feel inadequate because you didn't have the resources you needed to take care of your patients when you needed them. Keep on giving exemplary care to your patients and try and change whatever is standing in your way of doing that. Don't forget to take care of yourself. You matter too.

How long after getting the vanc did he transfer to the floor? You'll often see pressures drop after abx as the bacterial lysis releases vasodilatory endotoxins. I've just learned to anticipate it. I've also put my foot down on hasty admissions. I HATE when my reasonably sick pt gets a floor bed assigned within 1-2 hours of hitting my room. Those are always the ones with a yoyo'ing blood sugar or surprise hypotension. But bed placement would rather they get rapid response'd than take up an ED bed for more than 2 hours.

You cannot do everything all at once. You did what you could. WRT to septic patient, you noticed the AMS and reported it to all concerned parties. The patient was sick, that's why they were hospitalized (if they just needed fluids/abx they could go straight to a SNF. They are in an acute facility because it is accepted they have potential to decompensate.) Further, this one was booked to stepdown for a reason. A stepdown unit's purpose is to care for and monitor "borderline" patients at high risk for becoming critical patients. And to send those who need it to ICU. Sounds like that's what happened.

I think it's great you noticed the AMS and stepdown and the MDs had warning that they might go bad. You cannot treat decompensation until it happens (you don't amputate for every case of cellulitis just to make sure they don't get osteo). You gave appropriate tx for sepsis and monitored; what were you supposed to do, start "preventative pressors?" Septic patients crump. It can't always be prevented.

The diabetic wasn't there for glucose mgmt and it sounds like they weren't being admitted, at least at that point. If anything you'd expect a fever to mean high sugars. Regardless they were self-managing at that point-you didn't give details on how you noticed the low but you caught it somehow, treated it and [sounds like] no harm came to the patient. A sick diabetic will have wacky sugars at times; again you can't necessarily be expected to prevent a fundamental feature of the disease. You identified and treated it soon enough to prevent harm-you did fine!

ETA: when the MD learned the septic patient was more lethargic there were no new orders. I take that as confirmation that there was nothing else to be done for them at that point (again, once standard care is in place for the problems that exist, you can't treat potential problems until/unless they happen.)

I used to be (and still a little bit am) like you. I beat myself up a lot. But now, with time and experience I'm learning that we are human and these people are sick and if they tank and we have done everything possible, it's NOT OUR FAULT. When I have a patient who I'm iffy about going up to the floor as opposed to the ICU, I call the admitting doctor and tell them my concerns about the patient going to a unit other than the ICU. The vast majority of the time they agree with me and will change the admission to the ICU. If they disagree with me, I just document. If the RRT is called a few minutes after they get upstairs, that's on the doctor and not me, as I did everything possible to advocate for my patient.

It's great to care for your patients, that's our job, but I sense you are very very emotionally invested in these patient, as if they were your own mom or dad. That can serve a great purpose WHILE you are caring for them, but once they are out of your care in the ER (whether they be under the care of another nurse or admitted upstairs), there is no need to feel guilty about what happens after, you didn't do anything wrong.

You can't split into 5 of you to give each one of your pt's equal immediate attention and be available for the next incoming pt too. You are only human. No one died, you did the very best at that given moment. Isn't that all we can do is our very best?