Critical Values (Niki ponders on the job training for nurses)

Chapter 38

The chart notes written by the pediatric nurse caring for the little boy who died are scant. However, by searching the lab values, medication administration record, and the vital signs flow sheet in his medical record, I piece together a story of wrong assumptions combined with missed critical assessments.

The ER got the ball rolling well enough by drawing diagnostic blood work and admitting the boy to the pediatric unit, based on a phone consultation with our client, the pediatrician Dr. Straid. This small community hospital typically reserves a handful of beds designated “pediatric” for stable admissions, otherwise transferring unstable or critically ill children to larger, nearby children’s hospitals like the one I work for. Of course, someone would have had to recognize how sick this child was to trigger that response.

As I suspected, the results of the blood cultures drawn in the ER confirmed the severe bacterial infection, which ultimately killed the boy. These results were not available when he coded though, because it takes hours, sometimes days to grow out the killer organism. However, the complete blood count (CBC) results were available, including the differential, the cell-by-cell roadmap of the patient’s immune response. It’s white blood cell count (WBC) indicated a battle against infection, but it was the elevated number of new, immature white cells (bands) telling the story of the boy’s exhausted immune system. I searched the medical record to find documentation that this critical value was brought to Dr. Straid’s attention sometime before the child coded, but it wasn’t there. This is where the ball was dropped the first time: the nurse did not call in this critical result to the pediatrician if she had been aware of it. No one had, according to the patient’s chart. It’s the ancient law of the medical record: “If it isn’t written down, it didn’t happen.” I noted this on the yellow legal pad Grant had provided, to share with him later.

The nurse had entered a brief admission note, documenting the patency of the IV started in ER, administering the IV antibiotic, and that the bedrails were up. Her next entry described being called to the patient’s bedside by the parents, who were concerned about a pinpoint rash forming on their son’s trunk during the antibiotic infusion. The nurse called Dr. Straid at home, receiving an order for IV diphenhydramine and a steroid to treat what everyone assumed was an allergic reaction to the antibiotic. No mention of the CBC results during the phone call is recorded.

Of course, Dr. Straid could have taken it upon himself to come in from home to see his patient, I think to myself.

There are no further notes until the end of the nurse’s shift, when she recounts calling the code, and the failed resuscitation. I cringe for her while reading it. Poor woman. Was a lack of experience the reason for her failure to report the lab results, and the absent suspicion of an unidentified rash? I wonder how much pediatric training does this hospital provide its nurses? Cases like this one often become the catalyst for additional staff education, after the fact. Other times, nurses learn things the hard way, when a more experienced nurse catches their error during change of shift report, or from watching another nurse make a similar mistake.

I think about how Liz took it upon herself to mentor me when I was new to PICU, becoming a human safety net providing a layer of protection for my patients and me as I learned. I doubt this nurse had a Liz, at least not on this particular shift.

Poor patient. Poor nurse.

Seeking Justice (Niki reviews a nurse’s notes)

Chapter 37

In the conference room, Grant gives a brief explanation of the case I’m to review:

“According to the ER record, the parents reported their three-year old wasn’t interested in eating for a couple of days and when he stopped drinking fluids too they became concerned, bringing him to the hospital’s ER. A temperature of 102.5 was recorded, but otherwise his vital signs were normal, with a slightly elevated pulse. Concern for dehydration led the ER staff to draw blood tests, and start an IV. They decided to admit the boy to the pediatric unit for IV fluids, antibiotics, and observation overnight.

He arrived on the pediatric unit at 10:30 pm. According to the nurse’s admission note, he was lethargic. He received a dose of IV antibiotic within an hour of his arrival. After that, the order of events is vague. His mother noticed a rash on the boy’s chest and arms during the antibiotic infusion. The nurse called the attending pediatrician, who was at home, and reported the rash. The boy received a dose of IV diphenhydramine, and steroid to treat the rash assumed to be an allergic reaction to the antibiotic. The boy fell asleep.

The next entry in the nurse’s note records that an hour later she was called to the room by the boy’s parents. The rash had spread over his entire body. They were unable to rouse him.

The nurse documented a blood pressure of 67/45, a pulse of 50, and respirations of 10. She called a code, and the boy was intubated in the room. Resuscitation attempts followed. The attending pediatrician was summoned from home. He arrived half an hour later. Unfortunately, the resuscitation attempts were unsuccessful, and the child died.

Later, the results of the blood tests drawn in the ER revealed a severe bacterial infection, which was the cause of the rash, not an allergy to the antibiotic. The parents are suing the hospital and the attending pediatrician for wrongful death. Our client, the attending pediatrician, maintains that he is not at fault because the nurse failed to report the results of the blood tests, and how sick the child actually was. Therefore, the responsibility for the boy’s death rests on the nurse, and as her employer, the hospital.

What I need you to do, Niki, is review the chart, and find indications that the pediatric nurse neglected or did not follow standard practice in her care of this child; anything pointing to our client’s innocence.”

“Wow. Okay Grant. I’ll read through the record, and see what I can find.”

“Thanks Niki. If you need anything, let Claudine know. I’ll see in you in a couple hours. Raquel and I are looking forward to having you stay with us the next couple of days.”

“Me too. Thanks for inviting me, Grant.”

After Grant leaves the room, I settle into the leather chair at the large, polished table of the conference room, a hard copy of the medical record lying on it. Leafing through its pages, I feel queasy at the realization that whatever I find wrong will be used to blame another nurse. I dismiss the thought, however.

“I am a patient advocate,” I remind myself. “By reviewing the medical record, I’m helping a family receive justice.”

Something Cold & Diet (Niki turns nurse expert in a medical lawsuit)

Chapter 36

“I have to wait and see what happens next, Raquel. I won’t pressure Corey into leaving Sheila when she has breast cancer. There’s no moral ground for me to stand on. She’s his wife, after all.”

“It’s funny that fact only became important to Corey just now. That’s all I’m saying, Niki.”

“Jeez, Raquel, it’s cancer. What’s he supposed to do, abandon his wife, and kids? ‘Daddy’s sorry honey, he doesn’t love your Mommy anymore, but he’ll see you on the weekends!’ His girls are too young to understand. They’ll think he left because she got sick, and lost her hair. They’ll hate both of us.”

I’m sitting in my kitchen talking on the phone to Raquel, who like me, is sipping a glass of wine, our tradition of wine by phone.

“His girls are going to hate you for a while anyway Niki. You’re the woman he left their mother for.”

If he leaves Sheila, Raquel.”

“All I’m saying Sweetie, is look out for yourself. You nurses take care of everyone but yourselves. It’s your greatest gift, and your fatal flaw.”

“Let’s change the subject, okay?”

“Sure. Hey, I almost forgot: Grant wants me to ask if you’re interested in being a nurse expert on a case. He’s representing a pediatrician whose patient died. The family is suing, but the hospital maintains it’s the doctor’s fault, not their nurses. The pediatrician says otherwise. Anyway, Grant wants to know if you’ll review the medical record, and give your opinion. His office will reimburse your time and travel expenses. You can stay with us and make a weekend of it if you want.”

“Yeah sure. Tell Grant I’ll take a look. I have a four-day stretch off next week. It’ll take my mind off of Corey.”

“Thanks Niki. He’s hoping to keep his client out of court. You never want medical injury cases to go in front of a jury. It’s almost impossible for them not to side with the family. I don’t blame them. I’m mean really, a patient should be safe in a hospital, especially a defenseless child.”

“I know, right? It will be interesting to read the medical record.”

***

The next week I drive to La Jolla. Because it’s the middle of the school week, Maddie stayed with Simon, Amber, and Wade, which is her preference lately. I don’t blame her; of course she prefers their family household to my single mother lifestyle. What kid wouldn’t?

I take the elevator to Grant’s office, and check in with the receptionist. She makes a phone call, and in a few minutes Grant strides out of his office, giving me a big hug.

“How was the drive down?”

“Traffic wasn’t too bad.”

“Thank you so much for agreeing to do this Niki. It’s so helpful to have a pediatric intensive care nurse in the family, in more ways than one! I’ve had a table set up for your use in our conference room, with hard copies of the medical record. I can get you any other information you need. Just let me know. Have you had lunch?”

“You know, I’m not hungry yet. I saw a few restaurants in the neighborhood on my way in. If I get hungry, maybe I’ll take a break later and pick up something to eat. Is that okay?”

“Oh, sure, sure. Bring back the receipts. Your food and travel is on the firm. We really appreciate you using your time off for this case. Can I get you some coffee or a soft drink in the meantime?”

“Um, yeah, do you have something cold and diet?”

“Sure do.” Looking at the receptionist, Grant says, “Claudine, will you bring a cold drink to my sister-in-law in the conference room, please?”

“Of course.”