I am a new grad (4 month) working at a very busy long term nursing sub acute center. Yesterday morning I lost one of my residents. It is not the first time I lost someone, but this one got to me a lot more then others. This person who has end stage of cancer in pelvic cavity was found in the previous evening with a profuse bleeding from wound at the groin area (old deep wound). Nurses gave accounts of big clots passing through the wound. My colleges called 911 and resident was transferred to the hospital. Only came back a couple of hours later. No blood transfusion, No IV fluids were given. Only orders were to monitor the wound and to follow up with PCP.
When I assumed my shift, the resident was stable, no bleeding, vitals stable, no pain. I checked on him thought the night, checked vitals and a wound site for bleeding. All was good. Around 6 a'clock in the morning the resident started to complain of pain in a lower abdomen area. He often did in the last months. He had narc's to cover for pain and they were helpful. I checked wound dressing = dry and intact, no signs of bleeding. Checked vitals = WNL, BP on the lower side (92/50), but I expected that from the recent bleed. Yet something was different, I had this knot gut feeling. I was hesitating to give usual pain relief. I was concerned that there might be bleeding inside ( abd was on the hard side, but not rigid board like as I learned from textbooks in case of internal bleed ) and that pain relief would mask more serious problem. In addition BP was on a lower side and there is this side effect of lowering it even more. I wanted to call MD, only I didn't. I talked myself out of it. I said to myself there is no signs of bleeding, his dressing is dry and intact, vitals are as expected given recent bleed that day and no remediation for it in the hospital. The pain is expected for someone with the cancer in the pelvic cavity. I told to myself he's been on that med for long enough and will not be affected and he is in pain and needs pain relief. I gave him pain med and went to tend to the rest of my 47 residents who needed their morning meds too, 14 BS checks, 3 GTs and 4 IVPBs.
About an hour later I went to check on him again, found him screaming in pain and bleeding profusely from his wound. I yelled for help, we grabbed gauze still left by his bedside from previous evening, applied pressure to the wound , put him in the trendelenburg and initiated all the steps of the code. There was so much blood gashing from the wound, it would not stop. The BP at this point gone down to 50/20. As we were applying pressure on the wound, we saw the color disappear from his face , he was no longer responsive to us. 911 crew arrived and we worked more on him together. When they were taking him to the hospital he came back to us and was responding. I taught we got him back
When I came back to work, I learned that he didn't make it and died in the hospital an hour later.
Since then I have been replaying what happened in my head and feel responsible for his death. I should have listened to my gut feeling and sent him back to hospital. All my coworkers ( who are absolutely wonderful, ) kept saying they would do the same thing I did. What do you think? I want to learn from this experience so I can be better nurse and so at least I cna attempt to make sense of my resident's death.
Thank you and sorry it is so long
PS. Please be gentle to my English . It is not my native language and I haven't slept yet. Just been replaying what happened in my head.
sounds like the first hospital visit should have bought him hgb and preferably an observation bed regardless of the diagnostic results. that's what i would want for me in same position. who knows what was behind that would a big vascular mass or ? not good healthcare, but not much you could do sounds like. lot of bleeding do what you did, pressure, lay em flat, start an iv, put on defib/rhythm pads, call 911 asap, and get em out, fluid bolus, coagulation may have been an issue, where was the nursing home doctor? sucks to be you boss, that was a tough situation. better get a job in the hospital at some point so u can avoid some stuff like that. there is always some junk going on but at least in a big medical center academia goes a bit further. interesting post,thanks.
OP your english is great and I just want to say that I think you did a wonderful job. More importantly it is obvious from your post that you wanted to learn from your experience and as usual AN stepped up to the plate!!
I am sorry you had to go through this experience but I really believe that you will be a better nurse with the combination of the experience and the wonderful feedback you got. With me being a nursing wanna be, this post has been good information for me.
Keep your chin up, you are and will continue to be a great nurse. Be Blessed!!!:hug:
I was a 19 year old LPN - 6 months out of school. I was sitting at the desk finishing up charting for my 3-11 shift and the aides were directly across the hall finishing last rounds. One of the aides called out that "Jane" had a little bit of a bloody nose and asked that I come look at her. I finished up the last couple sentences and went to the room. Resident was sitting up on the side of the bed, talking with a drip......................................drip..................................drip of blood coming from her nose. She was talking to us and voiced absolutely no discomfort. As I'm taking vitals and trying to do assessment the drips become faster and within no time I instruct the aide to go get the more experienced nurse from the other unit. Within just a few more minutes the resident was unresponsive. Other nurse walks in the room takes one look and goes to call 911. Within just a few more minutes this resident is now having tennis ball size clots coming from her mouth one right after the other along with continued bleeding from the nose that is now just a river. Of course she was gone minutes after paramedics walked in. The whole thing couldn't have lasted more than 25 minutes from the time the aide called for me.
I share this with you because it has always haunted me. I was young and very green. For many years I just knew I must have screwed up and let that lady die (even tho the experienced nurse and paramedics all assured me at the time that there was absolutely nothing any of us could have done to save her - I just thought they were being kind). After 25 years of being a nurse, it is still easily the scariest thing I have ever been through but I also understand that they were right. Sometimes people just fall apart...sometimes they "fall apart" very fast and very unexpectedly. You will probably never forget this shift but I sincerely hope the day comes that you can be at peace with it. You did nothing wrong - tell yourself that over and over until you believe it.
Kid, You did nothing, I repeat, Nothing wrong. It's a fact in our business Patients die. The only thing that separates us from everyone else it that we dedicate our lives trying to
win little battles against an unbeatable foe - Death. Don Quixote ring a bell. You won't forget the patient's death but try and forgive yourself. Remember we are all here for you, if we aren't out fighting windmills.
I would have done the exact same thing you did. If you had called MD, he would have said to just monitor. Once I had a patient die right after getting to hospital and I was beating myself up over it and a nurse said to me "you can't always pinpoint what's wrong with a patient till it happens. They go from fine to not fine. You can't call MD or hospital and say" I think something is up with this patient but I don't know what. They'll think ur are crazy."
It's always hard when you lose a patient, but you didn't do anything to cause him to die, get worse, or bleed out. Pelvic centered cancers often erode thru veins and sometimes arteries, and I've lost patients before as they died in a massive wave of blood out of vg, orifice, catheters. I had one guy who was passing clots the size of my palm and all the doc would say was "just watch him." Watch him do what? Die? Often when a patient is a full code and so obviously doesn't need to be, you're going to see things just like your patient -- goes to hospital, shipped back with maybe a fluid bolus or pain meds given, because there's no real "fix" left. Nothing you could have done was going to make this guy live to see Christmas. It was simply his time. You'll never forget him, anymore than I've forgotten my first little lady that passed away.
Don't be too hard on yourself. It sounds like you thought of all the right things. Remember he had just been in the hospital and they obviously missed something since he only came back with orders to monitor the wound. I do like the reminder to listen to your gut and follow those instincts. If you feel uneasy about something at least a call to the on call MD can help reassure you. But do not beat yourself up. I think you sound very conscientious.
The hospital did not "miss" anything.
They knew he was dying of a necrotizing cancer, and there was nothing else they could do. The fault lies with the mis-communication between the hospital, primary and the nursing home who should have put a DNR order on this poor souls chart.
I was a 19 year old LPN - 6 months out of school. I was sitting at the desk finishing up charting for my 3-11 shift and the aides were directly across the hall finishing last rounds. One of the aides called out that "Jane" had a little bit of a bloody nose and asked that I come look at her. I finished up the last couple sentences and went to the room. Resident was sitting up on the side of the bed, talking with a drip......................................drip..................................drip of blood coming from her nose. She was talking to us and voiced absolutely no discomfort. As I'm taking vitals and trying to do assessment the drips become faster and within no time I instruct the aide to go get the more experienced nurse from the other unit. Within just a few more minutes the resident was unresponsive. Other nurse walks in the room takes one look and goes to call 911. Within just a few more minutes this resident is now having tennis ball size clots coming from her mouth one right after the other along with continued bleeding from the nose that is now just a river. Of course she was gone minutes after paramedics walked in. The whole thing couldn't have lasted more than 25 minutes from the time the aide called for me.
I share this with you because it has always haunted me. I was young and very green. For many years I just knew I must have screwed up and let that lady die (even tho the experienced nurse and paramedics all assured me at the time that there was absolutely nothing any of us could have done to save her - I just thought they were being kind). After 25 years of being a nurse, it is still easily the scariest thing I have ever been through but I also understand that they were right. Sometimes people just fall apart...sometimes they "fall apart" very fast and very unexpectedly. You will probably never forget this shift but I sincerely hope the day comes that you can be at peace with it. You did nothing wrong - tell yourself that over and over until you believe it.
Thank you so much! You got it exactly right. Everyone at work and 911 people and here on board are so nice and keep saying I did everything I could and nothing wrong. I am not young, but I feel very very green in this profession. Deep inside the feeling is that I screwed up and not only let that pure person die, but die in pain.
Till recently this person was very much alive. He was OOB all the time, happy and nice to us nurses. He talked to us. He knew and would ask about my girls at home and I knew about all his grand kids. He would come out in the hall to ask for something and we would talk while I am signing and getting it out of a med cart. Those little 2 minutes that I had before I had to run do something else where always pleasant and I was always looking forward to seeing him. He made me feel good when I was coming to shift and doing my rounds he would wave at me and say "Oh, good it is you tonight. How was your day?" It is because of my residents who are often like him I really love my job despite of the fact that I am underpaid and overworked in the unsafe conditions. I am really sorry he had to die this way. Even if, as people say, it was not my fault.
OP your english is great and I just want to say that I think you did a wonderful job. More importantly it is obvious from your post that you wanted to learn from your experience and as usual AN stepped up to the plate!!
I am sorry you had to go through this experience but I really believe that you will be a better nurse with the combination of the experience and the wonderful feedback you got. With me being a nursing wanna be, this post has been good information for me.
Keep your chin up, you are and will continue to be a great nurse. Be Blessed!!!:hug:
Thank you for your kind words. Yes, I am feeling a little more comfortable with English compared to 12 years ago when I came to US from Israel and knew only 5 words. And then thank goodness for the spell check in the Microsoft Word!
I hope that this experience will help you in the future when you will become nurse. It is long and hard journey before you get there. But it is very meaningful and worth full of a effort. Good luck to you in your journey.
It's such a shame that so many laypeople think that having a full code will help in these kinds of situations - if only the patient and his family had understood that resuscitation efforts would be futile then, instead of transfers to a hospital and panicked hurry and interventions, your patient could have died with you, in relative calm and comfort, and with his family at the bedside.
I'm sorry you've had this distressing experience - I agree with all the other members that your care was excellent and that there was no other outcome possible regardless of interventions, at your end or the hospital's. As nerdtonurse said, most likely the tumour/s eroded through major blood vessels - the patient looks fine, and suddenly they're really unwell, really fast, and then they're dead, with the family (and often the staff) shocked.
That's why all patients in this situation should be NFR - by all means treat reversible issues, like filling for hypotension, if that's what they want, but CPR etc cause distress, panic, massive staff adrenaline, reduced services to other patients, noise and haste for no good outcome. I don't know how we can help educate the public, but this is a perfect example of why we need to.
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jrodrig2
12 Posts
sounds like the first hospital visit should have bought him hgb and preferably an observation bed regardless of the diagnostic results. that's what i would want for me in same position. who knows what was behind that would a big vascular mass or ? not good healthcare, but not much you could do sounds like. lot of bleeding do what you did, pressure, lay em flat, start an iv, put on defib/rhythm pads, call 911 asap, and get em out, fluid bolus, coagulation may have been an issue, where was the nursing home doctor? sucks to be you boss, that was a tough situation. better get a job in the hospital at some point so u can avoid some stuff like that. there is always some junk going on but at least in a big medical center academia goes a bit further. interesting post,thanks.