Failure

I once failed three patients in the space of a weekend.

~ ~ ~

My first patient was a young woman, her left eye badly bruised, her lip split, her right cheek scraped raw, the subcutaneous tissue protruding from a deep laceration on her right arm.  Her clothes fit her poorly, she was covered with tiny scabs, and she couldn’t hold still in the room, constantly rising from her bed to walk to the door and peer out, then pace around her room again.  She tripped over her speech, unable to make eye contact with me.

I walked into her room, wrapped a warm blanket around her shoulders, sat on the chair across from her bed, and said, “Are you shooting meth, or smoking it?”

Her face fell, and shame flickered into her eyes.  I reached out and gently touched her arm.  “I don’t care that you’re using — I just want to know if you have access to clean needles if you’re shooting up.”

She shook her head.  “Just smoking.  I hate needles, I haven’t used needles in years.”

I nodded.  “Good.  Tell me what happened tonight.  What did he do to you?”

And she cried as she told me that all she wanted was to cuddle up to someone, to have someone hold her at night.  After they smoked meth they’d fallen asleep, but when he woke up and wanted to have sex, she didn’t, and she pushed him away.  And then he beat her.  He hit her in the face with a closed fist, he scratched her hips and her stomach trying to tear her pants off, he shoved her so hard that she flew backwards across the bedroom and crashed into a dresser, where a mirror had shattered and cut her arm.

Finally, as she lay on the floor of his bedroom, bleeding, he lit a cigarette and stood over her, screaming at her.  Why do you make me do this?  Why do you make me act this way?  I love you, why don’t you love me back?

Then she glanced down at her arm, and pulled away a dirty scrap of fabric that she’d held in place with Scotch tape, and showed me the two small, reddened, blistered circles hidden there.

I looked at them for a moment, then met her eyes.  “Those are from his cigarette, aren’t they.”

It was a statement, not a question, and she didn’t need to answer.

~

We washed out her cut and sewed her up.  I put antibiotic ointment on her burns, and covered them with clean gauze.  She held an ice pack to her eye, and as I dressed her wounds she told me of a childhood of sexual assault and abuse, a lifetime of addiction, her family dead, her children taken from her years ago.

“My little girls aren’t little any more,” she said, quietly.  “They probably don’t even remember me.”

I sat down in my chair again, and looked at her.  “I want you to know that I’m going to respect whatever choice you make tonight.  But I, personally, as a human, as a woman, as a nurse, want you to let me call the police.  I want you to make a report.  I want you to tell them what he did to you.”

Her gaze drifted away from mine again.  “What good will it do?”

“At the very least you can get a restraining order on him.  You can help keep yourself safe; if he walks through the restraining order they’ll arrest him and put him in jail.  He won’t be able to hurt you then.”

She was quiet for a few minutes.  I let the silence drift over us, over her battered face, the blood spatter on her jeans.  Then, softly, she said, “I already have a restraining order against him.”  She glanced up at me.  “And I went to his house anyway, because I didn’t want to be alone tonight.”

She shrugged.  “This is my own fault.  And I just want to go home.”

~

I walked her to the big double doors that exit the ER back to the lobby.  I put my hand on her shoulder.  “I don’t care if you went to his house.  This isn’t your fault.  It’s never, never OK for someone to do this to you.”

She nodded, and we both knew that she didn’t believe a word of it.

I put my arms around her and hugged her, wondering when the last time was that someone had touched her without demanding something in return.  “Please be safe,” I said, and she smiled at me, and left the ER.

And as I walked back to my computer to finish my charting and close out her chart, I felt like a failure.  What were the magic words?  What could I have said differently that would have unlocked her willingness to call the police?  What could I have phrased in such a way that she would believe, even if just for a moment, that she didn’t deserve to be beaten for being who she was?

Why, when I had pieced together language with such ease throughout my life, had it suddenly failed me now?

Another nurse stopped me in the hall.  “Hey, did you have that super sketchy meth chick?  She told the triage nurse that she fell off a bike, but I don’t believe that for a minute.  What’s up with that?”

I stared at him for a moment, and thought, He used her as an ashtray.

And when, in my shock, I fumbled through a mediocre explanation of what she’d endured, I felt like I failed her all over again.

~ ~ ~

My second patient was an old man with a bad heart.  When his exhausted and overstretched left ventricle could no longer keep up with the demands of his body, fluid backed up into his lungs and he began to drown inside his own chest.

We called the respiratory therapist and slapped a bipap on him, and within minutes his oxygenation improved, his respiratory rate slowed and deepened, and his frantically beating heart began to relax.  We x-rayed his chest, drew lots of blood, hung antibiotics for the faintest hint of a pneumonia.  We told his wife and son that he would be admitted, and they left to go home to get a little sleep.

I went back into his room to check on him again, and he tapped the mask.  He tried to say something underneath it, but between the heavy plastic face piece and the turbulent whoosh of air from the machine, it was impossible to understand him.  I put the bipap into standby mode, and removed the mask.

“What’s up?” I said, putting a nasal cannula into his nose to keep the oxygen flowing to his overtaxed lungs.

“I need my pain pills,” he said, anxiously.

I frowned.  “Are you in pain?”

“I’m always in pain; I have a terrible back, but that’s not the point,” he replied.  “I’m addicted to pain pills; I have been for years.  My doctor knows this; there should be a Care Plan on my chart.  I need to take narcotics every four hours, or I go into withdrawals.”  He glanced up at the clock on the wall, and grew even more nervous.  “It’s been six hours since my last pill.”

His candor caught me off guard.  It was not often that people admitted, openly and frankly, that they were addicts.  And fewer still were able to articulate that they needed their fix not to get high, but rather to prevent the withdrawals.  He didn’t really care about his back pain; that was just simply now a part of his life.  But he was terrified of the withdrawals.

“Let me go talk to my doctor.  Are you breathing OK now off the machine?” I asked.

He nodded.  “My breathing is fine.  But, please.”  He was begging now, and it was making me acutely uncomfortable.  “Please, please.  I need my pills.”

~

“He says he’s addicted to the pain pills, and takes them every four hours around the clock,” I said to my ER doctor.  “And, honestly, I believe him.”

The doc looked skeptical.  “His breathing is already terrible; I really don’t want to depress his respiratory drive by giving him narcotics.”

I raised an eyebrow.  “Sure, but I REALLY don’t want him to go into full-blown withdrawals.”  But then I shrugged.  I was out of time to negotiate this issue.  I had a GI bleeder in my second room, and a severe asthmatic in my third room, and I was behind on my work for all of them.  “Anyway, message delivered.”  The doc nodded at me, and I walked away.

~

An hour later, I glanced up at the bank of monitors at the nurses station and realized that my patient’s cardiac leads were off.  His pulse ox was obviously off his finger, and there was no BP recorded.  I was data-less.  I stood up and walked back into his room.

He was sitting at the foot of the bed, inches from pitching forward onto the floor.  His gown was puddled around his waist, his body shiny with sweat and dead pale.  He was gasping for air, and moaning in agony with each breath.

“Jesus fuck — I NEED A DOCTOR IN HERE!” I yelled, and grabbed him.  I hadn’t even thought to put gloves on, and my hands slipped on his bare skin.  Sweat was pouring off of him, saturating the bed.  I could see his pulse racing in his neck.

“Please, please, my pills, god, it hurts, please, it hurts, please,” he moaned, over and over again.  I eased him back onto the bed as the doc and another nurse rushed into the room.

I shot the doctor a look.  “He’s in withdrawals.”

“Give him dilaudid and benadryl,” he said, and put his stethoscope to the man’s chest.  “And get the tech in here for a repeat EKG.”

By the time I got back from the Pyxis with the meds, the other nurse had dried off the man’s chest and put the cardiac leads back on.  His heart was racing — 130, 140, 145.  His oxygen saturation was 9o%; he’d pulled his cannula off in his distress, and we cranked his O2 up to 6 liters to try to regain some ground.

I drew up the dilaudid, and slammed it into his IV.  Me, who dilutes everything.  I don’t even give Zofran undiluted.  Not this time.  I realized I was furious, my hands literally shaking with anger.  I took a deep breath, then a second, and diluted the benadryl, and gave it very slowly.

Then I watched the monitor, and wiped the sweat from my patients face.  His heart rate slowly began to creep down.  140.  135.

“Any better?” I asked quietly.  I was drowning in guilt.  I could barely force the words from my throat without feeling like I would choke on them.

“A little,” he replied.  “I’m sorry, I’m so sorry, I’m sorry –”

“You have NOTHING to apologize for,” I said, sick to my stomach.  “You were honest with us from the start.  You told us what would happen, and we didn’t listen.  We owe YOU an apology.”

“No, it’s my fault, addicted to the pills –”

“Do you need another dose of pain medication?” I asked, cutting him off.  I felt like I was moments from collapsing in tears of utter frustration.  I had completely failed this patient.  I hadn’t been his advocate.  My one job, my ONLY job, as a nurse, at the end of the day, is to care for my patient, to be their defender.  I was busy and stressed and didn’t fully believe him when he told me the truth.  I hadn’t pushed the doctor, and I should have.

I hated myself.

“Yes, please,” he begged, and I gave him a second dose of dilaudid.

And I wiped the sweat from his brow, and held his hand, and watched the monitor again.  130.  125.  120.

And then I realized he wasn’t breathing.

“FUCK FUCK FUCK FUCK FUCK!” I screamed, and grabbed the bipap.  The moment I pressed the mask to his face the bipap switched out of standby, and a huge push of oxygen from the machine flooded his lungs.

I adjusted the straps around his head as the machine helped him breathe, in, out, in, out, an endless battering of tidal waves of shame, drowning me over and over with every breath.

~ ~ ~

My third patient was a young mother with breast cancer.  Her right hand had become slightly swollen earlier in the day, and her oncologist told her to come to the ER for an ultrasound.

The ultrasound was inconclusive, and the doctor ordered a CT scan with IV contrast.  The contrast dye would light up her veins and arteries, and any clots in her hand or wrist would pop up brightly on the scan images.  She and I chatted as I set up the sterile kit to access her implanted port, sitting just under the skin of her right chest, which she used for her chemotherapy treatments.  It was a PowerPort, and could handle the pressure of the dye injection.

As I began to scrub the site, the patient suddenly paused in the middle of a sentence, and glanced at me, clearly hesitant.

“What’s up?” I asked, tossing the chlorhexidine scrub in the trash.

“Well, I was just wondering…you know, when I had the port placed, they told me that there was a risk of blood clots forming on the tip of the port, the one in the big vein.  Do you think there’s any chance there’s a clot there, and that’s causing my hand to swell?”

I froze in the act of opening the hollow core needle.  My patient misunderstood me immediately.

“I mean, you obviously know this stuff WAY more than I do, and if you think it’s OK to use the port then that’s fine by me –”

I dropped the needle into the sharp box, unused.  “You’re absolutely right,” I said.  “We shouldn’t use the port.  That’s a really good thought.  I’m glad you said something.”

I slid a peripheral IV into her left arm, and the CT tech wheeled her off to the scanner.  I sat in front of my computer, nauseated.

Of course there was a clot on the tip of the port.  It was starting to occlude the right subclavian vein, where it sat, and she was seeing the very first signs of venous congestion when her hand began to swell.  It was staring me in the face, and I’d missed it.  I was so used to just accessing a port that I hadn’t thought the process through.

My patient had saved herself.  From me.

I had failed my third patient.

The CT came back positive for the clot.  We admitted her to the hospital to have the port removed.

I went on my break and dozed off on the couch, and had nightmares of IV dye rushing through the PowerPort that I’d accessed, violently tearing the clot from the lumen, tiny clots scattering throughout her lungs, her heart, her brain, her organs failing in a rapid cascade, calling the code, and as I reached for the code button on the wall I reached out in real life and startled myself awake.

The break room was silent around me.

I threw my lunch in the trash, too heartsick to eat, and went back to work.

~ ~ ~

Over the past few months, for a variety of reasons, I found myself pondering a terrible question:  What would I do if I couldn’t do this?

What would I do if I couldn’t be an ER nurse?

I never came up with a good answer.  I never landed on a profession, on a different aspect of nursing that would give me the same satisfaction, the same joy, the same fulfillment.  There have been times in my life when I’ve stepped away from the ER, to do public health work, to fight an epidemic overseas, but in the end I’ve always returned to my home.  I’ve always walked back through the ambulance bay, hit the metal button on the wall, and stepped back into the chaos.

To be an emergency nurse is a fundamental part of who I am.

And every time I fail a patient, especially when I fail them in a way that could cause them grave harm — to send them back to a man that may kill them, to ignore their signs of decline, to cause a condition to worsen through negligence — I realize that my career is more tenuous than I ever imagined.

The gossamer thread of a single, deadly mistake could snap – and end it all.

~

A very good friend and I were talking a few nights ago, and the topic meandered into vulnerability.  “To be vulnerable is to be very brave.  And to love is to be the most vulnerable – and bravest – of all,” she said, and gave me a knowing look.

I gave her an arch look in return.  She was talking of relationships and marriages, and I, perfectly happy to avoid that topic for the remainder of my natural life, changed the subject.

But I realized later that it rang true for me in a completely different way — I was vulnerable when it came to my job, to my career.

Because I love it.

And to love something like that makes you vulnerable, and to be vulnerable is to be frightened, and fear expresses itself in innumerable ways — anger, cynicism, hate, impulsivity, and – in my case – mental and emotional self-flagellation.

I hate that I failed those three patients.  I was incredibly lucky that no one was injured, or further injured.  I am incredibly fortunate that I get to return to work tonight.

So in the end, I take my stories of failure, and I lay them out for the world to see.  I lay them out for me to see.  I pick them up, one by one, and turn them gently in my hands, looking at them from all angles, rubbing my fingertips over the jagged edges, running my palm over the smooth surfaces, working to understand them better.  To understand me better.

To allow myself to be vulnerable.

To allow myself to love something that is sometimes beyond my control.

And to allow myself to move forward again.

~ ~ ~