BIG mistake

yesterday, i made a BIG mistake at work. i've made mistakes before.

but this, this was the BIGGEST mistake i've ever made. there were potentially lethal side effects. and i cried like i've never cried before. in fact, i freaked out once i realized what had happened. and i fessed up immediately to the prescribing nurse practitioner and to the attending so that we could rectify the mistake, if it was deemed necessary.

i want to describe every last detail. all of the events that led up to hanging the write medication at the wrong concentration, hence overdosing my patient on morphine. but there are TOO many details. it's never one thing that leads to mistakes. it's a string of little things that typically leads to a disaster. and unfortunately, i'm the last link - at the bedside, closest to the patient, with the most potential to do harm even while trying to help. i want to explain away how it happened. to prove that i did ALMOST everything right. that i had THE very best intention in mind - to provide pain relief to my dying patient who was gasping for breath and whose wife was finally ready and willing to accept comfort care. but i hope that YOU (whoever YOU are) know that i am a safe nurse. that i don't practice carelessly. that i respect medicine and nursing and all of the potential mistakes that could be made. but i don't want to type a novel. i already did that in my documentation of the error yesterday.

suffice it to say, i gave my dying patient more morphine than was ordered. and although i had a second nurse double check my hanging of the potent medication minutes after i hung it, it was not until 6 hours later that the error was caught. and by this time, my patient had had more than 60mg of morphine. for those of you who know medications and dying, this is NOT an unreasonable amount of morphine to keep a patient with air hunger comfortable. Ten mg of morphine per hour is however, a VERY large dose to START a continuous morphine drip. i should have hung the morphine at 2mg/hr and instead, due to hanging a 5:1 concentration bag instead of a 1:1 concentration bag, my patient received FIVE TIMES more than was ordered.

here's the good news. i made this mistake on a patient who was VERY uncomfortable. he was in multi-system organ failure and his death was imminent, whether or not i made an error. his response to the LARGE dose of morphine suggests that his body "needed" the relief. he tolerated the morphine well; morphine causes respiratory depression and even with LOTS of morphine in his system, his respiratory rate was within normal limits. and without ALL of that morphine, my patient might have continued to be VERY uncomfortable.

here's the other good news. the nurse practitioner and the attending were VERY nice. they actually played a part in allowing this error to happen. and while i was sobbing and pouring my heart out (saying, "this is my forte. i'm good at dying. i'm so mad that i made this mistake because it's something that i am so passionate about"), they complimented me on my nursing skill. on my ease at discussing difficult subjects with very vulnerable people. on anticipating orders and advocating for my patient.

here's the best news. my patient was okay (as "okay" as a dying man can be). once the mistake was revealed, it was decided to leave the medication at the current rate of 10mg/hr. the patient was comfortable. his wife (and the other TWENTY family members and friends) was content with her decision to stop curative treatment and start comfort measures. she was at peace, seeing her husband calm. and although my shift was over before he passed, i know that i played a part in helping someone to die peacefully - which was my aim all along.

it's kind of ironic. i should be at work today. i am scheduled to be there. but my grandmother passed away on saturday in switzerland. and i'm taking bereavement. i get my next three shifts off. and you know what, i need a break. i need to grieve the loss of this patient, whom i had cared for numerous times. and i need a bit of time to heal my conscience of this mistake.

ice cream scooper?

sometimes i feel like my work days are too lame to write about on a blog. like they're just pills and IV antibiotics. vomiting and diarrhea. who would want to hear about that?

and then, i have days that are so newsworthy and so dramatic i can barely muster the energy to re-hash them here on this little blog. they're too hard to contemplate again. and i'd rather pretend they didn't happen at all, so that i could move on with my life in blissful ignorance of all the pain and suffering in the world.

on wednesday, my 35 year old patient whom i have cared for off and on since january during his numerous hospital admissions, had the courage to admit he was having suicidal thoughts and requested to see psychiatry. we take suicidal ideation pretty seriously in the hospital. or at least i do. because i understand depression pretty well. and this man has every right to be feeling like his life is miserable and that perhaps, he would truly be better off if he were dead (isn't that sad? i care for people whose quality of life is sometimes so low that i too wish for them to die).

i notified my patient's doctor. and we went in and sat in our patient's bed - together. all three of us in our 30s. two of us very healthy and privileged. and one of us teetering between life and death. one of us wanting to control his destiny by overdosing on the same narcotics that are supposed to treat his pain. my patient sat there are bawled. i HATE seeing grown men cry. and i HATE when other grown men, physicians, don't know what to say or how to handle hard situations. i facilitated the talking. i told him he is brave. that he is doing the right thing seeking help.

the rest of the day was a series of check-ins. check-ins with my patient (to assure his safety). with charge nurses (on my unit and on psych - to see if we were doing the right thing). with the psychiatry team of residents and doctors. with his oncology team of doctors. with his pharmacist. with the discharge nurse (as he was going to be DCd to home that evening).

and although i truly believe that i did everything right, i went home feeling anxious. what if my very sick patient did attempt suicide? what if he succeeded? what if he ended his misery? would i feel glad that he was pain-free and done with his transplant battle? or would i feel partly to blame? like i should have done something better or differently?

i won't mention the rest of the week. it's too long. and too sad. but suffice it to say, i don't have good weeks when my family is potentially ill. and i don't like for my patient's to be a shade of grey-blue while struggling to breathe. and i don't like seeing wives in the hallway, pacing while their husbands are "crashing" - as one of them put it. (note the plural. wive(S). we had two codes yesterday).

working at molly moon's, scooping ice cream, working on my biceps and eating samples all day, is sounding better and better.

miracle man

this week, after a long 12 hour shift, as i walked down the mile long corridor towards the garage and couldn't find my key card to get past some doorway, a nice nurse came up behind me and let me through. we ended up walking to our cars together and chatted the whole way. turns out, i know this woman. not SUPER well. but enough. and she knows me. what my family has been through. she was one of my dad's primary nurses when he was a patient at my hospital more than 14 years ago for five weeks.

at first we just talked about our respective jobs. about oncology versus cardiac patients. about the number of our patients who die. we talked about the "heroic" and sometimes not so heroic measures we institute to keep people alive. and about how sometimes what we do in medicine feels inhumane and morally wrong. then, for a brief second we talked about how i was supposed to work on her unit. how i got a job as a cardiac ICU nurse and quit about 10 days before i was supposed to start via email from kolkata, india.

and then, she asked. a question i assume she was hesitant to ask. because after 14 years of being a cardiac patient, sometimes the outcome is not so good. but she asked anyway. "how is your dad doing?" i beamed with pleasure. my answer was "good. great actually. he just returned from almost a month in europe, visiting his home country. and earlier this year, he and my mom went to china. they retired more than a year ago and it's been so good for him. for them." the nurse remembered by dad's deli. he had only owned it for more than a year when he fell so ill.

it was nice to talk about my dad. people often ask me about him. because they know how important he is to me. how much i love him. care about him. and worry. then the nurse said, "you know, it's amazing how much i remember about your dad. i remember you and your sister and your mom so well." i replied with, "well, we were there a long time." but LOTS of her patients stay a long time. lots of patients have heartbreaking stories and supportive families. she said, "i guess you remember the miracles!"

happy birthday to my favorite miracle! my dad turns 68 years young today. and i love him!