by Tilda Shalof
However, the vast majority of the incidents described are repugnant, even despicable. There are cases of nurses who had stolen money from patients and even one who had pilfered a patient’s dentures! There were tales of nurses who had been verbally abusive to patients. One nurse was reported to have tied a nursing home resident to a toilet and left her there for hours. Another nurse had sexually assaulted a comatose patient. Even such isolated incidents reflected badly on nursing as a profession. At some time in our careers, most of us have encountered wrongdoing, either mild or severe, and each of us knows privately what we did or did not do with that information. We know whether or not we had the moral courage to stand up for what was right or whether we looked away.
But I think most of us feel proud that the College of Nurses is there to protect the public and that these complaints are out in the open. After all, we all know that transparency, reliability, integrity, and accountability are hallmarks of professionals, and if bad apples are exposed in the process, so be it.
I suggested to Jenna that we meet at a Tim Hortons coffee shop near her house. I arrived on time but she must have been there long before me as I found her poring over a thick black binder full of notes, documents, and affidavits. She looked like she was cramming for an exam. She started when I touched her shoulder. I was shocked at her appearance. She had always been slender, but now she was gaunt and looked pale and unwell. She seemed fragile and was bent forward like she had a cramp.
“I’m terrified to come back to work,” she said as I brought her a cup of herbal tea and a coffee for me. “What are people saying?”
“They don’t know what happened, only that you’ve been off work.”
Jenna didn’t waste a moment. She needed to share this. “When they first called me from the College of Nurses, I thought maybe I had been chosen for an award, or something,” she said, slightly embarrassed. “I had no idea it was a complaint against me.” She shook her head at her naïveté. “There was a friendly message on my answering machine to please call them at my earliest convenience. When I finally got back to them, they told me a family had lodged a complaint against me. By then, they had seized the chart and all I had was a faint memory of the events.” I reached out to touch her hand. I wanted to offer support, but I reminded myself of the promise I made not to be swayed by emotion, to listen to all the facts as objectively as possible, and come to my own conclusions.
“Now, about the complaint itself,” I said, trying to help her stay on track.
“I didn’t have access to the chart but by then I had started to recall the case. It was a sixty-six-year-old woman. She was a fresh post-op repair of a perforated bowel due to an underlying malignancy. She had hypertension, diabetes, and coronary artery disease, too. Surely the family knew it was high risk surgery? She lost almost two litres of blood in the OR. Anyway, she arrested and we did a full code for more than an hour, but it was unsuccessful. She died that night on my shift but it wasn’t because of anything I did or didn’t do.”
“Did the family say it was?”
“Not exactly … but they said I hadn’t resuscitated her properly and that I hadn’t reacted when the alarms went off. They said I had turned them off. I did turn them off, but they don’t understand why. I was dealing with the problem. They also said I didn’t call the doctor soon enough and … they said something else.” Here Jenna fell silent, not yet ready to tell me the other thing.
We sat there for a few minutes until I prodded again. “What happened next?”
“I contacted a lawyer, even though I had to pay for it myself.”
“Why? Didn’t the union provide legal aid? That’s what we pay our dues for, isn’t it?”
“Yes, but I was afraid it wouldn’t be enough and I didn’t know what was involved. So far, the lawyers’ fees have cost me thousands of dollars.”
I looked at Jenna. I would have her as my nurse any day. But perhaps she’d been distracted by her infertility problems and not as careful or as focused? “We miss you at work,” I said. “How are you managing?”
“It hasn’t been easy. Technically, I can still work. I haven’t been suspended because it’s not a criminal trial, only an investigation of a complaint, but I haven’t been feeling well. One good thing has happened during this time. I am six weeks pregnant,” she said glumly. “I know I should be happy, but I’m just so stressed over this other thing that I can’t even think about it. Besides, I’ve gotten pregnant before, but never made it past the fourth month.” She sipped her tea and then looked away. “I feel very alone with all of this. I appreciate your meeting with me, Tilda. Others have called, but I just can’t face them.” She started to sob, but then sat up straight and blew her nose. “Okay, I’ll tell you everything.”
I nodded. “Yes, go on.”
“When I came on to my shift that night, the patient had just arrived from the OR and I knew right away I was dealing with a very unstable patient. I asked the resident to insert a new arterial line because the one put in in the OR had a dampened waveform.” She drew a diagram of the poor waveform on a paper napkin with her fingernail. “I took the patient’s pressure by cuff and it was around ninety systolic, the diastolic undetectable. She was in normal sinus rhythm with a rate of about sixty-five, with no irregular beats. None.” She shook her head for emphasis and took a deep gulp of air as if needing more oxygen to carry on up this mountain. “The doctor was trying to get the line in and the family kept calling from the waiting room, wanting to come in but I had a lot of work to get done first.”
How well I knew this situation. Many nurses want to wipe up all the spills and messes before letting families into the room. Maybe it is because I know personally how important it is for families to be there, that I always let them in right away, especially when the patient is so critically ill. But Jenna kept them waiting and I could imagine how that might turn out to be a problem.
“Maybe you should have let them in. So what if they see the mess?” I interrupted.
“But doesn’t that just add to their stress? It adds to mine because then they start freaking out and asking questions and I can’t concentrate on what I’m doing for the patient.”
“I know, but that’s how some families grasp what’s really going on.”
“But doesn’t there have to be trust?”
“I agree,” I nodded. But there are some things that need to be seen to be believed, and the controlled chaos of resuscitating a patient as sick as Jenna’s patient was, is hard to imagine if you’ve never witnessed it.
“Well, anyway, I thought I would get that arterial line secured, draw up some emergency drugs, just in case, and tidy up the room before letting them in. Meanwhile, the patient was very restless and I couldn’t leave her side for a moment. She was agitated, tearing at her lines. Her abdomen was taut and distended. She was pale and clammy. I needed to draw blood work such as hemoglobin and hematocrit, since she’d lost so much blood in the OR. Her temp was high at 38.8 C and I had a peek at her X-ray and could see she was developing pneumonia, so I wanted to draw sputum and blood cultures. She was on maximum ventilator support, with one hundred per cent oxygen. I was also getting worried because she wasn’t putting out much urine.”
“She might have been going into pre-renal failure due to her low kidney perfusion and compromised cardiac output,” I said, thinking out loud.
“That’s exactly what I was thinking.”
“Okay, so …”
“Meanwhile, the family kept calling, wanting to come in, but the patient was still thrashing around. The doctor ordered sedation, but I gave only a small dose because I was afraid it would drop her blood pressure even more. She was terribly agitated, and I tried my best to calm her down by talking to her constantly, even though she was still under the effects of the anaesthetic. I explained that if she pulled out any of her lines, she would be in grave danger. I told her that those things were helping to save her life. She kept grabbing at her tube. I asked the doctor if I could restra
in her arms and he nodded okay. Then, he had to run off because he was called away to another patient. He never wrote that order and that turned out to be a problem later. Make sure you get a doctor’s order for restraints, Tilda. Take it from me.”
I nodded, thinking that I probably would have restrained her, too. There were many situations when restraints on the arms, and sometimes legs, too, as extreme as it sounds, did help patients through a temporary time. Sometimes, even mild-mannered people become combative when they are critically ill. I have cared for agitated patients who pulled out their arterial lines and hemorrhaged, and others who pulled out their breathing tubes and injured their airways. (I will never forget one patient in particular. She punched me in the chest and in the shoulder, and I was getting upset. Even the physiotherapist refused to treat her until she stopped being violent, but nurses can never deny someone nursing care. I had to find a way to protect myself. Reasoning with her wasn’t having any effect and the sedatives were only working minimally. As a last resort, I felt I had no choice but to put soft restraints around her wrists, but that made her even more agitated. I was trying to figure out what to do when her daughter happened to call.
“My mother was a political prisoner in Argentina,” she explained. “I think that’s why she’s so upset at being confined. If you restrain her it will only make her more frightened.”
I nearly tripped over myself in my haste to remove those restraints, but by then, the patient had thoroughly exhausted herself, the sedation had kicked in, and we were both worn out.)
Jenna was ready to continue. “I was just about to call the family when they showed up at the door and barged right in. At that moment, the cardiac alarm went off and I turned and saw that the heart rate had dropped to forty-four. I ran to give her an injection of Atropine to bring the heart rate back up and while I was doing that I silenced the monitor, another thing the family later objected to. They didn’t realize the problem was her low heart rate and I was treating it. Then they asked, ‘Why is she tied down?’ but I couldn’t explain at that moment because I was busy dealing with the low heart rate. In their letter of complaint, the family claims they asked for the restraints to be removed, but I don’t recall that. When families say no restraints, I always ask them to stay with the patient because I can’t be there every moment to ensure the patient doesn’t harm herself.” Jenna looked away and tried to compose herself. This must have been what she was reluctant to mention earlier. The use of restraints is a very contentious issue.
I nodded. “It sounds like you were justified in restraining her, but let’s face it, haven’t you ever known a nurse who used restraints because it was easier than talking someone down or waiting for sedation to work? But anyway, go on.”
“Yes, of course.” She paused to find her train of thought. “But I swear to you, Tilda, I would rather face this trial than have a patient that sick yank out her airway or lines. Can you imagine if she had pulled out her endotracheal tube? We would have had to re-intubate her or even do an emergency tracheostomy that would have been even more traumatic. Can you imagine if she had pulled out her central line, how she would have bled and I would have had no intravenous access? She would have arrested without lines in place!”
We looked away from one another. This patient had died. However, had the team been unable to make every attempt to save her it would have been a worse failure. To us, restraints were the lesser of two evils, but the family clearly didn’t see it that way.
“Oh, dear, who knows what is right?” Jenna said. “Here’s the worst part. Just as they were getting ready to leave for the night, and I was saying to them, as I always do, that I would call if there were any changes in the patient’s condition overnight, the alarm sounded and she blocked right down and went into cardiac arrest. I shooed the family out of the room and immediately started chest compressions. Casey called on the intercom for the doctor and the crash cart. He arrived about one minute later, but the family must have assumed I was doing nothing in the meantime. There was no chance to explain anything, but I could hear them outside the door getting hysterical. By then the room was packed and we were all working on her. We pulled her up and got a hard board underneath her so that the compressions would be effective. Man, they were so effective, I could hear the ribs cracking. I hate that sound, don’t you?”
We both winced simultaneously at the thought. To me, what was even worse than hearing that sound was knowing that your efforts have only a slim chance of actually saving the patient.
“It was a full code. It went on for more than an hour. Each time we stopped CPR, we lost her.”
Jenna stopped to take another sip of tea, even though it must have gone cold. She looked so despondent that I wasn’t sure it was helping her to go over these details, but it was definitely helping me. I could picture the entire scene – the old woman intubated, her arms tied down, the stains on the bed, people pushing in syringes of drugs, and the family clamouring outside the door, angry, confused, and terrified.
“The code went on and on,” Jenna had to finish the story. “I pushed epinephrine and vasopressin and we shocked her again and again. We hooked her up to an external pacemaker to buy some time. All the lines were wide open and we were pouring in drugs and fluid and all the while continuing chest compressions and ventilator breaths, switching with one another every ten minutes, so we could keep up our strength. We soon saw the direction it was going. The surgeon arrived, ready to take her back to the operating room, but by then, it was way beyond that. Her pupils were fixed and dilated. She had no heart rhythm whatsoever. When we told the family, the daughter fainted and had to be taken down to emerge.”
We sat quietly together, thinking all of this over.
“Unfortunately, all of this took place right at the start of my shift.” Jenna spread out her hands across all of the notes. “We hadn’t had time to build up trust. I feel disappointed that our attempts to save her life aren’t appreciated, but the patient was high risk to begin with. Surely they were told of the possible complications beforehand?”
She showed me the letter the family had written the College of Nurses. “What was the nurse’s motive in silencing the alarm?” they’d asked. “What was she trying to hide by pushing us out of the door with no explanation of what was taking place?” they wanted to know. “The nurse gave our mother a needle, then the monitor went flat and she told us to get out. Next thing we knew the doctor came to tell us our mother was dead. Why didn’t the nurse call him sooner?”
Jenna explained, “I got up on the witness stand and explained everything as best I could. Our manager attested to the fact that I was a safe nurse with a good record. The family were furious. I tried to tell them how sorry I was for their loss, but they turned away when I spoke.”
“What was the outcome of the hearing?”
“It’s still before the committee. They will announce their decision in a few weeks.”
As we said goodbye, I hugged her and wished her good luck. We both knew, but didn’t say, that if it did not go in her favour, Jenna could lose her nursing licence. I wished her well with the pregnancy and her health, because much more was at stake here than her career.
A month later, I called to see how she was doing and if she’d heard anything.
“The matter has been settled,” Jenna said wearily. “At least for now.”
“What do you mean?”
“The committee’s decision was to take no action. They said I had not breached professional nursing standards and that I had responded in a timely and correct fashion to the emergency, but the family is appealing the ruling so the final verdict is still pending.”
How conversant she had had to become in this forbidding language, relaying it without emotion, sounding neither encouraged nor vindicated, neither bitter nor disheartened, either.
“How are you feeling, Jenna?” I asked cautiously.
“I’m having problems with the pregnancy, bleeding and cramps,” she said dully. “I’ll be
off for a while on bed rest to try to prevent a miscarriage like last time.”
“You must be relieved that this trial nightmare is over.”
“Yes, I am,” she said quietly, unconvincingly.
I thought about all that Jenna had done and not done. In my opinion, she acted professionally and competently that night, but what she had neglected to do was let the family in immediately. Perhaps if they had seen for themselves, they would have realized that everything possible was being done to save their mother. Jenna’s desire to protect the family from seeing a messy, frightening resuscitation worked against her, even though her intention was good. In the end, it was a sad story of a grief-stricken family trying to make sense of their loss and an aggrieved nurse caught in the middle. There were no winners.
