by Tilda Shalof
“Let’s be clear about this,” said Morty. “A mistake is not necessarily a crime. Let’s hope she won’t be treated like a criminal.”
“I can just imagine her, crying by herself at home,” said Nicole. “I bet everyone’s coming down on her.”
“But not nearly as hard as she’s coming down on herself,” I said, putting myself in that nurse’s place for just a few uncomfortable moments.
Tracy was characteristically quiet, but it appeared she was thinking hard.
“At the very least, there’ll be some ’splainin’ to do,” Laura said with a grim face.
“How will she ever be able to go on? How will she ever return to work?” How can she ever face the others?” I voiced the questions that were on all of our minds.
“How did it happen?”
“Surely she knew that you can’t dialyze a patient with ordinary sterile water!”
“Wow, without a buffering agent, a hypotonic solution like that would suck all the sodium out of the cells in a few minutes. A person would practically implode. Geez …”
Part unearned smugness, part genuine humility, nonetheless, we were all shaken; no one could rest easy. It could have been any one of us. It could have been me. Easily.
ONE QUIET MORNING, years ago, not long after I had started working in the ICU, I decided to give my patient a bath. Andy was a middle-aged man, a father of two, with acute leukemia. He was in the ICU battling one infection after another, following a long course of chemotherapy. The number of platelets he had in his blood stream – those cells responsible for the body’s normal clotting mechanism – was nil: zero. I re-read the lab results. No platelets? Zip? Zilch? How was that possible? I closed the chart and prepared the bath. His temperature was raging. He nodded weakly in assent when I told him what I proposed to do.
“Andy, just lean over so I can wash your back.” I helped him reach for the side rail. “That’s it, a bit more.” He was too weak to pull himself over alone. “Grab on to the side rail,” I instructed.
He did as I said, leaned onto the bar for support, and it broke.
The crash, when his body tumbled out of bed and hit the floor, along with the clang and clatter of equipment – iv pole, pumps, and ventilator – that were pulled down with him, reverberated throughout the unit. Everyone came running. I watched the swarming melee. I felt sick.
“Grab his legs!”
“I’ve got his head!”
“Easy now, let’s lift him up together on the count of three.”
“Careful,” I croaked. “He has zero platelets.”
Three days later he died. From infection, from internal bleeding, from cancer itself. He had a lot of reasons to die, but the fall out of bed didn’t help. Rosemary called me into her office.
“The bed was old and likely defective. You had the side rail locked into place properly. You did nothing wrong. Because of what happened, we’re replacing all the beds in the ICU with brand-new electronic beds. Something good has come of this. I want you to know, Tilda, that you did nothing wrong.”
“But he died,” I said dully. Perhaps I was absolved, but a man had died and I’d had a part in it. Was there something I could have done differently?
“We told the family exactly what happened. We’ve offered our sincere apologies and sympathy for what happened. They’ve accepted it. Now put it out of your mind,” said Rosemary. “Go forward. We all support you.”
I did as she said. I put it out of my mind. Otherwise, how else could I have gone on working there? Yet every once in a while something jolted me – it was either something I did or something I saw someone else do – and I was humbled and made grateful. From time to time, something would make me stop, check myself, remind myself to take more care, not take anything for granted, and not get sloppy. It all could be otherwise in a single careless moment.
Once, my patient’s iv tubing had a cracked connection that I hadn’t noticed and the patient’s blood leaked out into the bed, along with the medication he was supposed to be receiving. Easily rectified, that one. I cleaned up the patient, changed the sheets, and gave the med again, but whew, I thought – that was a close call.
I WAS CHATTING with my patient’s wife. Her husband was sitting up and starting to wean off the ventilator. He was working hard at breathing and she distracted him with joking banter because he often got anxious and short of breath when he was told it was time to work on weaning. Some nurses had suggested I cover up the clock on the wall. He would wean better that way, not counting the minutes the whole time, but it felt devious and I couldn’t bring myself to do it.
“I’m going to get you for this – all you’ve put me through!” his wife told him, giving him a light slap on the shoulder. It was a joke she could make only now that he was on the mend. He smiled weakly.
“You better be good to me when we get home, ’cause I’ve been through hell because of you!”
He nodded. The road to recovery since his surgery to repair a thoracic aneurysm had been a long and difficult one.
His surgeon came in and greeted him warmly. “Hi, Mr. Trute! How’re you doing? It’s good to see you out of bed. I’ve come to discuss the results of your tests.”
The wife and patient looked at me in alarm. I looked at the doctor in alarm.
The problem was that this man was Mr. Szabo and he had not been expecting test results. Furthermore, if the doctor got the patient’s name wrong, what else might be wrong? If the name was wrong, were the treatments also wrong? Maybe those meant for Mr. Trute (whoever that was) were the ones given to him? What about the surgery, the medications? Worst of all, was the picture the doctor held in his mind not that of her husband, Felix Szabo?
“Excuse me,” I interposed and explained the situation.
“Oh.” He consulted his notes, apologized lavishly, and fled the room.
Later that day when I told Morty what had happened, she found it greatly amusing. She told us a story and whether it was an Internet joke or something that had really happened – the way she told it we couldn’t tell – it made us howl.
“So, this nurse is taking care of this patient, see, and he says to her, nurse, please check if my testicles are black. What? she says. Of course not! Your testicles aren’t black. He asks her again. Nurse, please. Check if my testicles are black. Nonsense, she says. Forget about it. He asks yet again. Are my testicles black? So she throws back the covers and examines him. Holds each one in her hand, moves his dick to the right, then to the left. Nope, she says, your testicles aren’t black. Are you satisfied? He looks very taken aback and pulls down the oxygen mask that was muffling his voice. ‘Nurse, I was asking if my test results are back.’”
DESPITE ALL OUR checks and double-checks, despite backup systems and safety precautions, mistakes were still made. Before we hung a unit of blood or plasma, we verified five different pieces of identifying information with another nurse. We double-checked each other’s doses of insulin, digoxin, dilantin, and heparin, or any drug if we were unfamiliar with it. If we didn’t know a drug inside out – its actions, interactions, contraindications, and adverse effects – we didn’t give it until we learned everything about it. When Dr. Huizinga told us one night that it was okay to go ahead and give an experimental drug that hadn’t yet been approved for nurses to administer, we held fast and didn’t give it. How much more careful could we possibly be?
“One day, when medication orders, dosage calculations, and even the dispensing and labelling of the drug are all done by computer, errors will be eliminated,” the pharmacist predicted. “It will minimize the human factor.”
Yes, but it is nurses’ unique role to maximize the human factor. Will monkeys or robots be able to give the drug, explain its side effects, and make adjustments as needed, as nurses do? Will the accuracy rate be higher? Computerizing everything also brings its own set of new problems: it eliminates critical thinking and problem-solving and decision-making skills. What it does – and it did this very thing when all the
laboratory orders and reports were computerized – was create new avenues for error.
We nurses checked and second-guessed ourselves constantly. The doctors did too.
Dr. Leung called me one night from her home. I glanced at my watch. It was 0330 hours.
“I was mulling over your patient’s renal failure,” she said.
In her voice, I heard the pull toward sleep and the opposing pull toward wakefulness.
“I think we’re going to have to give him a whopping dose of Lasix to see if we can stimulate his kidneys.” She took a deep breath. “Tilda,” she said, “I’m going to ask you to give 320 mg.”
I gulped. The maximum I had ever given was 80 mg. “That much, Jessica?”
We were both thinking of the many possible toxic side effects of that large a dose.
“His creatinine is 398,” I said at the same moment that she asked, “How much is his creatinine?”
“Let’s give it a try,” she said. “Take it from me as a verbal order and I’ll sign it in the morning.”
“I don’t know,” said Laura, thinking it over. “I trust Jessica, but –”
“We’ll back you up,” said Tracy. Nicole, Morty, and Laura did, too. They all co-signed the medication record beside my signature, as I slowly injected the drug.
By the morning, when the day shift came on, the patient’s kidneys were working. Urine was flowing. The only problem was, the drug had made the patient stone deaf.
“It may not be permanent.” I stayed late that morning to hear Jessica explain to the family what had happened. “He may regain some hearing. It’s a side effect of the drug at that high a dose, but we had to give it a try in order to save his kidneys.”
“My husband,” the wife sobbed, “is a professor of music.”
“PATIENTS ARE DYING from the wrong doses of chemotherapy,” Daniel Huizinga announced one morning on rounds, apropos of nothing in particular. He held up his index finger to indicate that a caveat was on its way. “The problem is that patients are also dying from the correct doses of chemotherapy. Which is worse? It all amounts to the same thing. We are fallible human beings who know so little about the human body. The public is paying us to be certain, to fix everything, to have all the answers. Understandably, that’s what they want. We are all human beings doing the best we can, but they don’t care, they just want their loved one better.”
If this was the expectation, how could we ever measure up? Of course, the public had the right to be angry when things went wrong, but how could we, as nurses, make sure to do everything right all the time? Even if we did everything correctly, it didn’t guarantee that the patient would get better.
Sometimes when patients’ conditions worsened, the families would rush in and ask, “Who did this?” or “How could this have happened?” or “What went wrong?” Surely something was done improperly, something was not caught quickly enough, they seemed to say. Someone must have overlooked or mismanaged something, they implied. Yet, in my experience, this was rarely the case. People were sick. Many got sicker. Some got better.
Dr. Huizinga was right when he said that things could go wrong even if everything were done correctly. However, even if everything was done correctly and wrong words were used, that to me seemed like a mistake, or at least a miscalculation that could cause harm. Words could be medicine; I believed that. I had seen them used to heal and to comfort and to encourage. Words could be used in such a way that they were just as damaging as some mistakes I knew of.
On rounds one morning, well within earshot of my patient, Dr. Huizinga speculated about her marked, unexpected improvement.
“Why is this patient getting better?” he demanded.
“Well … I … I guess the treatments must be working,” said the resident.
Daniel shook his head. He was determined to hear everything opposite. “It will be interesting to see a tissue sample report from the autopsy.”
“We’ll have to wait just a bit for that,” I said and closed the patient’s door.
“Why is that?” he snapped.
“Well, she’s still alive. She’s doing better.”
“You know what Huizinga’s like,” Laura said to me later. “I’ve heard him say to a patient who had made a suicide attempt, ‘Did you do it? That was stupid, don’t do it again. Get help. But if you are planning to do it again, do it properly next time. No halfway measures.’ That’s his idea of a psych consult.”
Yet I couldn’t reconcile his abrasive manner with his supreme dedication and his expertise in action. He was the doctor I would choose if I had a critical illness, yet at times, I could hardly bear to exchange even a few words with him.
ONE DAY DR. David Bristol came into my room to talk to my patient, a forty-year-old Ethiopian woman who was in our ICU with bleeding from internal injuries after her husband beat and stabbed her in a rage because she had not borne him any sons, only daughters. She had also recently been diagnosed with breast cancer.
When I came into the room, Dr. Bristol was already in the midst of the conversation.
“Mrs. Afework, you have a very serious illness and now life-threatening injuries. If your heart stops, do you want us to perform cardiac compressions? In the event that you become unable to make decisions for yourself, someone will have to make them for you. If you require a breathing tube put down into your windpipe, do you want it? It is important that you get organized to ensure that your needs will be taken care of. Where is your family?” He looked around to see if there was a brown-skinned person around to translate his words into Amharic.
“I don’t have any family. I am alone.”
“Do you have a friend, someone?”
“I have no one.”
“Let’s suppose you become unconscious. Who’s going to make decisions for you? What about your financial matters? Is someone taking care of your children? There is a department of the government that we can contact, and they will make decisions for you or you will have to appoint a substitute decision maker. These are important decisions.”
I came to her side after he left. “Did you understand what the doctor said? Some things to think about, in case anything happens, you know, down the road.”
She clutched my arm. “Please, nurse,” she pleaded. “Don’t let that doctor call the government. They will take away my children.”
Perhaps he didn’t harm her with his words, but he didn’t use them to help.
I had been a critical care nurse for many years and was beginning to understand something about these situations that hovered in between what is truthful and what is cruel; what is compassionate, yet wrong; what is correct, yet harmful. I had also come to understand that it is more complicated than merely assigning blame. It wasn’t just that many people were involved, or that we were terribly busy, or that there were many distractions – though all of these things were true. It was that there were so many nuances, shades of meaning, and interpretations involved, and these things could have effects as serious as mistakes. How could mistakes be avoided or rectified, how could the problem be redressed other than by first seeking to understand from all sides, all angles?
AT LUNCHTIME ONE day in spring, it was finally warm enough to sit outside. We escaped into the sun on a grassy hill at the front of the hospital lawn and leaned against an outré industrial brass sculpture of interlocking cubes. Bruno joined us that day, and Belinda, too. Frances thought to bring with her a yellow bedspread from the linen cart and we spread it out like a tablecloth on the grass to eat our lunches. It helped us pretend we were having a leisurely picnic, when we all knew that our circumscribed forty-five-minute lunch break would soon be over.
As usual, Nicole brought a whole head of lettuce and made a salad. Bruno had a spicy chickpea roti he’d bought from Navreen, whose Jamaican take-out business was booming. She kept up her real job in the hospital’s laundry department, but continued to run her cottage industry from home and supplied our unit. Her menu had expanded to include rice and peas, meat pat
ties, and curry goat. We paged her on her beeper if we had a roti or jerk craving any time during the day. Her number was listed on the blotter at the nursing station, under “Roti Lady,” in between Respirology and Social Work.
First we caught up on gossip.
“… Tina’s labour went on for three days, and then she had to be induced. Alexa is having an affair with a married doctor … Erica had another miscarriage, poor thing …”
I decided to ask them about what had been uppermost on my mind, ever since that fatal error a nurse had made with the dialysis solution.
I had been preoccupied with the subject of fallibility ever since a case was reported in the media of a rock star suing the doctors who had treated his brother; he had died of a simultaneous cardiac arrest and a bowel obstruction. It seemed that if people had a lot of money or celebrity, they could make these public malpractice allegations. Their way of thinking must be something like this: What other possible reason could there be to explain why our beloved brother died, other than someone must have screwed up?
The way the media reports these events did not always help clarify these complex matters, either. I recently read a newspaper headline: “Drug used to execute death row prisoners was given to hospital patient who died.” That drug was potassium chloride and I have given it many times to patients. Given correctly, which it almost always is by nurses every single day in all hospitals, it can save lives. It is KCl, two essential elements, bonded to make a third. Sugar can sweeten or kill; morphine, gasoline, and fire can help or harm, too.
“What’s the scariest thing that ever happened to you with a patient?” I asked them.
Belinda offered hers easily. “That’s easy. I was a new grad and I accidentally switched meds on two patients, but they were both cardiac patients, so it more or less worked out okay.”
