Monday, May 10, 2010

Dirty Little Secrets of Nursing, Part Three: We've all killed somebody, except when we haven't.

Every nurse fears killing someone. New nurses fear it the most, because they don't understand the safeguards in place to keep it from happening. Older nurses, if you get 'em liquored up and they trust you enough, will certainly have a story about something that seemed...off, that they didn't catch in time, and that led to a patient's death.

Because we're with those sick and vulnerable people more than anybody else, we tend to take the responsibility for their deaths on ourselves--even when it's doubtful that anything we did or didn't do led to that death.

I have my own story: an older guy, in his eighties, with a blood calcium level that was horrendously low, had a cardiac arrest. He couldn't have gotten calcium IV, because he was already in physical rehab, where peripheral IVs don't exist. Further, because of his history of chemo in peripheral veins (that's how they did it back in the day), he was an impossible stick and refused to consent to a central line. And he wouldn't take the calcium supplements by mouth that I'd been ordered to give.

I rode his chest down to the CCU, doing hundred-per-minute compressions the entire way. He died anyhow. For a time I believed that I, Nurse Jo, had killed the guy. Whenever I had a brand-new nurse under my wing and something went Seriously Wrong, I would consider telling them about That Guy Who Died. Once, I think I did.

Thank God for CCU training. It helped me understand that all the oral calcium supplements in the world wouldn't have brought his blood calcium levels up enough to make a difference.

And thank God for further experience. His decision to forego a central line was his; pushing one on him would've been unethical at best.

Yes, the patient died. I thought I had killed him. Maybe I contributed to his death: maybe I could've been more convincing, or pushier, or more skilled at making him realize that what I wanted him to do was really necessary. At the end of the day, though, he was sound of mind, if not body, and made his own decisions. The fact that he couldn't have known that those decisions would lead to his heart stopping is kind of beside the point: we don't overrule personal autonomy for might-bes.

It's a dirty little secret of nursing: Sometimes, we kill people. Sometimes we only think we do. Sometimes, we're unsure...and that uncertainty is worst of all.

4 comments:

me said...

Pt. = end stage COPDer... per her sisters' request, she was made a DNR/DNI. Rx ~ 2 to 10 mg. MSo4 IVP to control air hunger.

Ayep.

David said...

It is kind of like a medication error, every nurse has made one and if they say they haven't do not trust them.
If you have been a nurse long enough you have pushed a patient towards the edge, and sometimes over.
Hell sometimes they are doctors comfort care orders to keep increasing the morphine until the end. Nice that they are not the ones doing it.

torontoemerg said...

I think the worst is when and you find out patient XY, perfectly stable, alive and about to be discharged when you left the previous evening, died overnight, and you think holy crap! what did miss? (Usually nothing, actually. People sometimes just up and die.)

My personal --- well, as you say, get me liquored up and I might spill it.

messymimi said...

Nurses are brave people.