Patients dying as a result of DOCTOR'S mistakes

mattsmom81 · Mar 14, 2002

Oh, what a heart wrenching story, Healing Touch!!

And as we say "been there, done that, got the T shirt..."

although it doesn't make us feel any better when this sort of thing occurs. To realize TPTB will indeed turn their malice to the nurse if we speak up is a sobering thought. We have all the accountability and zero authority....and we have to live with our own consciences too which may be the worst of it....... We second guess ourselves and rarely gain much peace of mind , do we?

( I chant the Serenity Prayer on a regular basis...LOL!)

Thanks for sharing and God bless! :)

live4today, RN · Mar 14, 2002

On two different occasions that are still clear in my mind are the following scenarios:

(1) Patient was having a spinal tap. I set up the necessary supplies for this to be done, and positioned the patient for the procedure. Young resident-in-training comes into the room smacking on the remains of a sugary doughnut. Proceeds to do the spinal tap. He didn't wash his sugary fingers, and he didn't don any gloves that were laid out for him. As he started to touch the sterile field, I said in a loud instructor type voice, HOLD IT, DOC! DON'T YOU DARE TOUCH MY STERILE FIELD WITH YOUR DIRTY FINGERS! He froze in his position and looked at me with a very pitiful and embarrassing look. He said, "What did I do wrong?" I said in a softer assertive, but politer tone of voice, You didn't prepare for the procedure in the correct way, and I won't allow you to continue unless you wash your hands, don those sterile gloves that I took the time to provide for you, and explain to the patient as you go what you are doing to relieve his anxiety.

The doc walked over to the sink, washed his hands, dried them, donned the sterile gloves, and proceeded to do the spinal tap with my assist as needed. After the doc was done, he thanked me, he said a few words to the patient and left the room. The patient said, "Is he new?" I said, Honey, they are all new when it comes to certain things that they must adhere to. We both broke out laughing! :chuckle

(2) Patient unconscious, on a vent. Doc and his team of medstudents came into the patient's room to check the patient by looking at him...no one touched the patient. They just stood there by the patient's bedside while "Dr. Arrogant" stood by explaining everything with his hands behind his back. As I got ready to leave the patient's room, the doc says, "BTW, I want a different IVF for this patient. I left orders on his chart at the desk.

Now, mind you, the patient's body is already swimming in fluids. As a matter of fact, fluids were oozing from his pours from head to toe, especially on his body parts below the neck region. His skin was so translucent, you could see through it because of the amount of fluid present. So, I turned to the doc, and said, If you want this patient to receive more fluid, you will either have to give it yourself, have your medstudents give it, or assign another nurse to this case. He said, "Why is that?" I said, Because this patient expired hours ago. Take him off the vent and you'll see that he won't respond. I don't understand why you keep telling the family members that this patient is "improving" when you know he's just been kept on that vent for the sake of your medstudents learning purposes. (I was an agency nurse who had worked three dayshifts in a row with that same patient with no improvements noted, other than his body was about to swim away.) The doc said, "So you think he's already dead, huh?" I said, I don't think, I know. He told one of his medstudents to check the patient's pupils to see if he could get a corneal response. I watched the medstudent perform the task up close and personal, and saw no corneal reflex, but the medstudent swore he saw one. So, the doc tried to get a corneal response, and wouldn't admit that he didn't get one either, he just asked me to get the Nurse Manager, which I did. The nurse manager, myself, the doc, the medstudents, and another RN stood by to witness the doc unplug the vent from the patient. He watched his watch, then looked at the patient, then back at his watch, not once did that patient react to being off that vent. No chest movements, no nothing. The doc stood tall, then pronounced the patient dead, gave the time of death to be noted, walked over to me and shook my hand saying, "Your a hell of a nurse, Miss ?" I said, Mrs. Hill's the name. He said, "Your a hell of a nurse, Mrs. Hill." After the doc and his crew left the patient's room, the Nurse Manager shut the door to the patient's room, and let out a big "Yeowzaaa!" She grabbed me, hugged me, and asked me if I wanted a job on her unit. I said, No thanks! Agency works best for this divorced mom with three kids to raise. She said, "None of us have ever challenged that doctor because of his smug attitude with us. He's made some of my nurses run crying into the nurse's break room. Thank you for taking him on. We suspected they were just keeping that patient on the vent for the benefit of the medstudents training, but no one wanted to tell that doctor that. Thank you, thank you, thank you!"

It pays to be an assertive nurse, and not let the "monkeys" bite you when you know what you know what you know. Scared of losing my job??? NEVER! I always had my patients best interest at heart, and wouldn't tolerate some doctor mistreating them for their own selfish reasons.

mattsmom81 · Mar 15, 2002

I liked your story Renee..but have some questions..were there no cardiac monitors, BP's or pulse, heart sound checks for 2 hours on this patient and why wasn't the lack of same noted and a code called? What was documented on the IV flow sheet for vitals?Or are you referring to brain death alone? Was the pt a DNR and left on the vent anyway to trick the students or? Just curious as this scenario sounds so wierd....but truth is often stranger than fiction. LOL!!! :)

4XNURSE · Mar 15, 2002

04/22/01

"0150 ...rechecked BP - 76/53 - HR 135 - RR 40 ....

0153 notified Dr. _______ (orthopedic) via phone of pts. BP.... No orders received, asked Dr.________ (orthopedic) if he wants nurse to notify physician on call for Dr.________ (internal medicine) - He states "NO". ________RN."

This is an excerpt from the actual nurses note. The RN waited another 2 hours then called internist. Too late!

My father died.

Yes! I am certain that if the Orthopod had let the RN call when she first wanted to, The internist would have picked up on the dehydration, (3 days of N/V, and diahrrea, with almost no PO intake) given some fluid, and my dad would be alive today.

No! I don't fault the understaffed, overworked RN.

"Has anyone personally seen......?"

How personally did you mean?

ken :devil:

live4today, RN · Mar 15, 2002

Originally posted by mattsmom81
I liked your story Renee..but have some questions..were there no cardiac monitors, BP's or pulse, heart sound checks for 2 hours on this patient and why wasn't the lack of same noted and a code called? What was documented on the IV flow sheet for vitals?Or are you referring to brain death alone? Was the pt a DNR and left on the vent anyway to trick the students or? Just curious as this scenario sounds so wierd....but truth is often stranger than fiction. LOL!!! :)

Hi mattsmom! :)

As an agency nurse floating onto the scene, I was so curious about why that patient was kept on a regular med/surg unit without all that monitoring equipment. I do recall that he was a "NO Code" as was written in his med records by the doctor who kept him on the vent all that time. As I stated earlier, I had this patient for three dayshifts in a row, complained the entire time about him to the staff and the Nurse Manager because that same doctor kept reassuring the patient's family members that "there had been no change, but there was still hope". HA! Hope my a-s-s! :rolleyes: Yes, vital signs were charted on him qshift as ordered. On the day in question, the patient had no true vital signs since he was dead and the only thing keeping his heart beating was the machine which is why I told the doc I would not continue to treat that patient because I truly believed he was no longer with us. The whole case was upsetting to me, and I had to take a stand with that doc for the family's sake! It was so obvious to me that the doc was using that patient as a guinea pig for his medstudents, but this smart a-s-s nurse (me) came along and blew his cover. :chuckle Do you think he wanted to stand before his train of medstudents and admit to them that the patient was already dead? I doubt it! That wasn't "Dr. Arrogant's" style!

You are right about that case being weird. To this day, I still think about it. How cruel to use patients in the way that doctor did -- all the while leading the patient's family members to think their loved one stood a chance of coming out of his "comatose state". At that time, I had only been out of nursing school six months, so I was still a new grad to many on that floor, but I know a rat when I smell one.

4XNURSE · Mar 15, 2002

Right on Renee!

Too bad more nurses don't stand up for their patients.

ken :devil:

mattsmom81 · Mar 16, 2002

Oh, Ken, your story about your father is so sad and I would not be as forgiving of the poor overworked nurse in this situation.

While I understand forgiveness helps the forgiver and my heart goes out to you, I would have most certainly taken the facility, docs and nurse to the cleaners here as this sounds like negligence pure and simple.

God Bless.... I've lost both my parents in the past few years and miss 'em both something terrible.

Renee, I worked some agency at some chronic vent facilities too and I recall a few incidents like you describe, now that you've jogged my memory. Dead guy on a vent, looks like he's breathing so he must be alive until someone looks closely, actually touches the patient or checks vitals. Sad.