Priorities Can Kill: When Passing the Buck Gets Dangerous

Jacqueline.Damm · Feb 13, 2019

I couldn't breathe. My chest was aching with a fierceness that made me want to pass out. There was a pounding echoing in my ears so loud that I could hear my heart coupled with irregular breathing. Where did I screw up?! Inside my head I could hear my own voice screaming. What did I do?! I wanted to be sick. WHAT HAPPENED?!

The morning rushed before my eyes in a blur. The checklist started: Report was normal, I had read his labs, the initial assessment was benign-- why would things change so drastically and so fast?! I then remembered a nursing school professor tell me once that the smaller the patient, the faster you run. Unfortunately, this patient was a full-grown adult male and in a matter of 15 minutes he went from talking to me about what he wanted for lunch to unresponsive and gasping for air. What did I miss?!

I did the only thing I could think of... Call the rapid response team, STAT page the doctor and then pray that my patient could hold on long enough for another brain and set of skills to arrive on the scene.

My hands shook as I spiked a bag of saline to bolus a blood pressure that was steadily and rapidly circling the drain. His mean arterial pressure reading should have rang, whistled and had its own blinking emergency lights. When I looked up from our vitals machine the CNA was staring at me completely horrified. She began to edge closer to the code blue button. "Stop!" I forced out. "He has a pulse and he's breathing. Not yet." My words sounded foreign. Not yet?

Standing in the doorway I quickly read through his labs again. Everything was in the red but not critically red.

Then I saw it.

The big ugly culprit.

"Oh no. No, no, no, no."

His bicarbonate level leaped from the screen, almost lost among the metabolic panel electrolytes that are often reported with an oddly brainless faithfulness... The level was TWO days old. Each previous reading had literally been flirting with metabolic acidosis. And yet, there was no critical flag attached, no page to the doctor charted, no addressing of the situation what-so-ever (not even brought up in report or noted that it has been called to the nurse from the appropriate lab source). This critical value had slipped through the hands of doctors, nurses, and the laboratory team before now.

I looked over and watched the accessory breathing on my patient's chest. If I didn't do something now this man will be leaving this World today and at any minute. Responsibility crashed down with a vengeance as my mind rushed into the hyper-speed fueled by fight or flight. It really was life or death now.

Rapid response arrived with a flurry of orders. My resolve grew stronger at the site of my fellow nurse with her familiar rosy cheeks and flustered hair. We started hanging drip after drip. A fourth and fifth bolus, Trendelenburg positioning and then the big guns. 'I NEED DOPAMINE NOW!'

Somehow the dopamine was calculated, spiked, hung and started while we were simultaneously checking blood pressure, EKG changes, mean arterial pressure, capillary refill, placing oxygenation via a non-rebreather mask, calling the doctor (who wasn't answering the numerous STAT pages placed) and calling the Intensivist for a bed in the ICU. We begged for intervention without our hospitalist's orders, the ICU doctor had to be the one to make the call.

When the transfer order was placed in the system, I had the urge to go, go, GO! With minimal staff, we rushed my patient's bed down the corridor and burst into the intensive care unit. The hospitalist I had been paging all morning was left in our dust, looking utterly dumbfounded. I felt my blood boil at the sight of her standing there. I wondered what was so important in her day that she couldn't answer multiple STAT pages. I had to shake my head to release the past with my ill feelings because the present was ever pressing and malicious.

A scene unlike any I'd ever experienced emanated before my patient's bed as we rounded into his new room. It seemed as if the ENTIRE ICU was waiting there for us. My throat tightened and I wanted to weep. Knowing that regardless of the situation fighting to kill the man in my care, the culmination of what had been done and what was to be done could all be the things needed to save him.

The next moments unfolded like a dance. A fine waltz where everyone knew their turn, where they were going and knew the next steps needed to be. In a matter of minutes, multiple other IV sites were placed, a tube was in my patient's throat, a ventilator had been set, and all seemed relatively calm and controlled. My head was spinning after blurting out report over the rush, the waltz, which had come to an abrupt halt. Each individual in that room had listened to the details of my care that morning. Few questions were asked, some eyes were wide with disbelief and then, it was over. My role in this man's life was over.

I watched the milky bag of Propofol dripping through my patient's line and almost fell into a safe-guarded trance as the room fell silent, faint beeping echoing in the back of my mind. I slowly collected the tubes and tanks, linens and bed to return to my unit. My fight and my advocating were over. It was only now I felt as though I could breathe. The urgent need to continue praying for the man I had been talking to only hours before pressed down like rushing water. The phrase, "I hope he lives, please live, I hope he lives," played over and over in my head like a broken record.

Please, let it be so.

Upon returning to my unit, I addressed the physician that had successfully missed every call and page from me that morning. My mind has blocked the probable but likely inappropriate chiding and urgent requesting of more prompt response and attention concerning patient needs and emergencies in the future. At some point, I recall sitting down to write a S.A.F.E. report about the lab value that was missed and never acted upon or further investigated.

A week or so later I was getting off the elevator from the cafeteria. A woman exited that I recognized. It was my patient's sister. Fear gripped me for I knew what to ask and what I needed and wanted to hear. I stood tall and asked the dreaded question, "Is he still here? In the ICU?" She smiled a big smile. 'He's been off the ventilator for days. He's sitting up, talking to everyone, even eating and walking. He's going to make it out of here.' With that, she turned and headed on her way with a reassuring nod.

I stepped into the elevator and crumpled, nodding, as if in another trance. He's okay, you're okay, he's okay, you're okay. I wept for the few seconds I had to myself before getting out of that elevator to finish my shift.

In honor of a life that was almost taken by medical mistakes and a lack of action, I challenge all of you to remember that your role as a nurse is heavy and great. But, it is your duty to investigate, to ask questions and push to be the biggest and best patient advocate at all times. It is a great responsibility to have this on your shoulders, but without everyone working together for the greater good, we have the chance to do harm, cause pain and even hasten the end of a precious life.

Priorities Can Kill: When Passing the Buck Gets Dangerous

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