I Guess We’re Going to Find Out

Chapter 73

I’ve been home for three days now. Maddie stayed home from school too, but I think she’s comfortable that I’m safe now, and wants to go back to being with her friends.

Raquel and Grant are staying in the guest room. Grant handles all media inquiries with an authoritative, “No comments at this time.” Raquel took all household tasks from me, and cooks a meal when take-out doesn’t sound appealing.

Honestly, I’m grateful to let them take charge. I’m not sleeping very well. It takes a long for me to drift off, and once I do, I’m wakened by horrible nightmares: sometimes Frank has me up against the wall, with his fingers around my throat, instead of Liz. Or, I am forced to pull the plug to Nathan’s ventilator from the wall, only to discover it’s Maddie in the hospital bed, screaming silently.

The ER doctor gave me a prescription for Ativan. I take one before going to bed, but it doesn’t work.

I’ll need the Ativan soon though. My parents are arriving any day now to relieve Raquel and Grant. I begged them not to come, but they insist.

Don’t get me wrong; I love my parents. I really do. Our family isn’t unusual for having some dysfunction, but as Tolstoy pointed out, “Happy families are all alike; every unhappy family is unhappy in its own way.”

Once upon a time we were a happy family.

I was six years old when my brother Joel was born. It was just like getting a living baby doll. I quickly adapted to the role of big sister, or more accurately, self-appointed co-mother.

I sat near (my mother would say, practically on) him all of the time. When mom nursed him, I sat beside her, shirt up, with my baby doll held against my bare chest in imitation. I got so close up when mom changed his diaper that more than once I was hit in the face with a stream of his urine. Whenever mom let me hold him, I was ecstatic with love for my tiny, baby brother with curly black hair…

“Hey Niki, you’ve been journaling with that faraway look in your eyes for awhile now. Are you okay? Can I get you anything?”

I put down my journal and pen. “No, thanks Raquel. I’m okay. I’m writing about Joel. I guess Mom and Dad’s visit is making me think about him.”

Raquel tenses and pales. The corners of her mouth and eyes slacken a bit.

“Honey, are you sure it’s a good idea to dwell on that right now? I have the phone number of the therapist the social worker gave us. Would you like me to schedule an appointment for you?”

“No Raquel, really, I’m okay. I’m sorry for upsetting you. I shouldn’t have said anything.”

“It’s okay, Niki. I’ve been thinking about Joel too. I hope Mom’s doing okay.”

“I guess we’re going to find out.”

At The Time I didn’t Know Either

Chapter 70

The nurse comes back. “You have a few visitors. “

Raquel rushes into the makeshift bay, and tries to hug me as best she can while I lay on the gurney. Following close behind are Grant, and Simon, escorted by Officer, I mean, Mike

“Raquel, Grant, how did you get here? And Simon?”

“You listed me with the hospital as your emergency contact,” says Raquel. “They called me. It just happened Grant had a legal conference in LA today, and I came along to do some shopping. We weren’t far when I got the call. Oh, Niki…” Raquel starts to cry. I look for a box of tissues, but don’t see one. I let it go.

“Then I called Simon. I called Mom and Dad too. I’ll call again later and let them know I talked to you. If I call them now, we’ll never get either of them off of the phone.”

“Oh God, Mom and Dad know?”

“I had to call them Niki, after I found out. It was too serious for me to wait. I didn’t know if…”

Raquel doesn’t finish the sentence. I know what it was she didn’t know.

At the time, I didn’t know, either.

There Must Have Been Some Kind of Disaster

Chapter 69

“Niki, are you okay? Did he hurt you?

“Officer Mike?”

“Mike, yeah. It’s just Mike. Officer isn’t part of my name.”

I let that sink in for a moment, before beginning to tremble violently. Officer Mike, I mean Mike, looks concerned, and grasps me by both elbows.

“I need a wheelchair over here now!” he shouts.

“Hey, that’s my line.” I try to smile, and then I realize he’s calling the wheelchair for me. A nurse brings one, just before my legs buckle out from under me.

Mike runs alongside the wheelchair, while the nurse rapidly pushes it to one of those medi-surg tents set up in the hospital parking lot. Off to the sides are reporters with cameras flashing, held back from the tent by armed men in fatigues.

There must have been some kind of disaster while I was in the room with Frank.

With Frank…Frank’s dead. He had a gun pointed at my head. He wanted me to euthanize Nathan. He held me hostage…hostage. Oh my God, Frank is the disaster!

Suddenly, I’m sweaty and nauseous. I my vision starts getting black at the edges, as though I’m looking through a telescope.

“Get her out of the chair and on the gurney! Start an IV and hang NS! Get her supine, she’s passing out!”

On the gurney, I barely feel the IV poke. The NS is chilly in my vein. I’m shivering. The nurse who got the wheelchair has a warmed blanket, which she places over me. It feels nice. “Better?” she asks, while taking my blood pressure and temperature.

“Yes, the warm blanket feels good.”

A doctor introduces herself, but already I’ve forgotten her name. “Niki, are you hurt anywhere? Did he assault you in anyway?”

I feel sick again when I realize what she means.

“No, no he never touched me. He had a gun pointed at my head. He slammed Liz up against a wall though, she’s unconscious…Oh no! Where’s Liz? Is Liz okay? What about Nathan? Are they okay?”

I start to cry.

The doctor takes my hand, and with the other wipes the hair from my forehead. “They’re in separate bays. We’re checking them over for injuries now. Liz is conscious. She’s getting a CT. Nathan is sedated. He’s going to be fine.”

She examines me, and then asks, “Niki, would you like something for anxiety, something to calm you?”

“Yes.”

I feel warm as the medication does its job.

Betting That Frank Doesn’t Know

Chapter 67

I forced myself to take a deep, inaudible breath before beginning.

Speaking slowly, I try to ignore Frank’s gun aimed at my face.

“Frank, okay. If you want me to put Nathan’s sedation back the way it was, then I need to take this little pump here off the IV pole, and put it on his bed. Is that okay, Frank? Is it okay for me to unclamp the pump from the pole so I can put the sedation back the way it was?”

Frank tilts his head and squints eyes, indicating he’s unsure if he believes me. Then he smiles, remembering he still has the gun. He answers confidently,

“Sure, that’s okay, but don’t try anything funny. I will shoot you.”

I nod my head to acknowledge I understand him. Gingerly, I unscrew the pump’s clamp lose, and remove it from the pole. I now have a projectile in my hands, but I’m unsure when or how to use it.

“Okay Frank, now I have to turn off the pump, and slide the syringe of sedation medication out of it. I’m going to give Nathan more of the sedation to make him sleep by pushing the plunger on the syringe.”

I know that if I push too much fentanyl too fast into Nathan, his back will arch stiff as a board from the bed, and he will code. But I’m betting Frank doesn’t know this. Maybe I can stall for time by giving Nathan just a tiny bit at a time.

God, please send someone to rescue us.

Like an answered prayer, the bedside phone rings.

Frank and I stare at it.

“Answer it,” demands Frank.

The phone rings again.

“Answer it!”

“Hello?”

When it Happens to One of Your Own: Niki’s Heartbreaking Admit

Chapter 60

It’s 1730, and I’m caught up on patient care. Not only this, but so are my coworkers. It’s been a quiet dayshift, but none of us say this out loud, because that’s the fastest way to jinx your shift. I helped Craig transfer his last patient to pediatrics, and he’s left early. The remaining three of us sit at our pods and finish charting. We have an hour left before night shift arrives.

Of course, it was too good to last. The phone rings and Sue picks up the phone. I can tell by what I overhear we’re getting an admission. A trauma. A motor vehicle accident.

It’s a fifteen year-old boy, intubated by paramedics at the scene. He was the unbelted passenger of the truck his buddy was driving. They crossed a freeway barrier, and hit an oncoming car head-on. Our patient flew at least thirty feet before hitting pavement. He coded on the scene. There was a fatality in the other vehicle. The driver of the fifteen year-old’s vehicle survived without significant injury.

We call respiratory, and a ventilator is set up in the room. I pull out kits for arterial and central line placement. Neurology calls to have us prepare for an ICP monitoring device insertion.

It’s all hands on deck as the paramedics roll the boy into the PICU. He is strapped onto a back board, and wearing a neck collar. I step up to the gurney as we prepare to transfer the young man onto the hospital bed. He’s unconscious, and there’s blood spattered on his face. His face: I take a closer look, and I recognize his face! Oh my god; it’s Liz’s son, Nathan.

An Awkward Silence (the trouble with bullies)

Chapter 42

Melissa took a sip from the glass of water in front of her before speaking.

“It was supposed to be my night off, but I came in extra at 11 for an eight hour shift. There was a sick call, and when they got a third admission that night, the charge nurse asked me to come in. I took report on the new admit from the charge nurse, who’d settled him into his room with his parents, but nothing else, because she was busy helping another nurse with a transfusion.”

“Did you have other patients assigned to you that shift?” Grant interrupted.

“Yes, I had three other patients, besides, you know.  One’s IV was out, and I needed to restart it. I did vital signs on the new admit, and hung his antibiotic first, though.”

“So, you assessed Bobby and started his antibiotic within an hour of his arrival on the pediatric unit?”

“Yes.”

“And then you went to another patient’s room to start an IV?”

“Yes.”

“When did you return to Bobby’s room?”

“I went in when the pump alarmed that the antibiotic infusion was finished. That’s when the parents pointed out Bobby’s rash.”

“Were you concerned by the rash?”

“Yes. I took another set of vital signs, which were unchanged. Then I called Dr. Straid at home.”

“To report the rash?”

“Yes. I was worried that it was serious. It was all over his body, even his cheeks. He seemed more lethargic than when I’d seen him earlier.”

“What time was this?”

“It was after midnight. Dr. Straid told me that Bobby’s lethargy was due to his needing sleep, and that I should stop over-nursing him.”

“But Dr. Straid was concerned about the rash, and ordered treatment for Bobby, didn’t he?”

“Yes, he ordered IV diphenhydramine and an IV steroid to cover the rash. The next dose of antibiotic wasn’t due until morning, and Dr. Straid said to hold the dose until he came in to assess the patient.”

“Did this sound like a reasonable plan to you?”

“No. Bobby seemed more sick than tired to me. His parent’s said he wasn’t acting like himself. I asked Dr. Straid to come in and see him then.”

“Because the boy had a rash, and was sleepy?”

“Lethargic, I used the word lethargic.”

“Were you aware of the severe neutropenia?”

Melissa looked at the hospital lawyer, then her hands folded in her lap before looking at Grant and answering softly, “No.”

“So Dr. Straid was unaware of the lab results. You asked him to come to the hospital in the middle of the night without looking at or reporting the lab results. Do you think that if Dr. Straid had been aware of the severe neutropenia he would have come to the hospital to see Bobby immediately?”

“Maybe. I don’t know.” Fierceness flashed in Melissa’s eyes at this inquiry.

“What do you mean, you don’t know?”

“I mean Dr. Straid has a reputation for not coming in to see his patient’s when asked by a nurse. I mean that most of the nursing staff is afraid of calling Dr. Straid in the middle of the night because he usually bites their heads off.”

“There’s no notation in this patient’s chart that Dr. Straid refused to come in, or that he was rude to you on the phone.”

“I’ve stopped writing about Dr. Straid’s behavior a long time ago. Writing him up doesn’t do any good. Nothing happens.”

“So you assumed Dr. Straid wouldn’t come in to see this patient because he is sometimes rude to nurses? You knew that reporting the lab results was useless?”

Melissa sat in awkward silence.

“Did Dr. Straid refuse to come in to see the patient after you told him the lab results?”

“Objection!” The hospital lawyer said quietly.

“Melissa, did you report the lab results to Dr. Straid?”

“No. I did not report the lab results.”

“Why not?”

“Because I hadn’t seen them.”

I sat in conflicted silence. She should have looked at the lab results before getting on the phone with Straid. She should have trusted her nursing instincts that the boy was gravely ill. Anxiety over calling Dr. Straid in the middle of the night, combined with a busy shift, and inadequate staffing got the best of her, an all too familiar story in nursing. The result was catastrophic.

 

 

A Tiny Diamond in Her Nose (The deposition)

Chapter 41

Extending his hand to introduce himself, Grant stood up to meet the nurse and hospital lawyer as they entered the conference room. Then he introduced me as part of the legal team.

I don’t know what I’d expected, but I was surprised the nurse facing deposition appeared to be in her thirties. Like me, she wore a dark blazer over a fitted blouse with dark slacks. Her blonde hair hung above her shoulders in an angled bob. Under the fluorescent lighting of the conference room, a tiny diamond above her pierced right nostril flashed when she turned her head, and a quarter-sized tattoo of the sun on her wrist was visible beneath the cuff of her blouse..

I also sport a tiny diamond in my nose, and a tiny red heart is tattooed at the nape of my neck. This is going to be harder than I thought.

I’d guess the hospital lawyer to be in his sixties, with a shock of thick, silver hair. The absence of telltale clipper marks as it formed around the shape of his head bespoke of a meticulous, and expensive scissor cut.  He wore a navy blue jacket, which he carefully removed before taking his seat at the table, revealing a pale blue dress shirt with French cuffs. His formal attire was at odds with Grant’ business casual look: a sport coat over an open neck dress shirt, no tie, and khakis. I got the sense something was being communicated between the two of them, but I couldn’t quite grasp the message.

After introductions, Grant explained that the deposition is a discovery process performed under oath, and would be videotaped.

“Before we begin, would anyone like a glass of water?”

“Yes, please.” Grant poured a glass of water for Melissa, the other nurse, from a pitcher of ice water and set of glasses conveniently placed on the table.

“Okay, let’s begin,” Grant started. “Melissa, how long have you been a Registered Nurse?”

“Seven years.”

“And, have you been employed at Sand Bluff Hospital for all of that time?

“No. Only for five years.”

“Have you worked all of those five years on their pediatric unit?”

“No. Only the past three years.”

“Were pediatrics part of your nursing school curriculum?”

“Yes.”

“What pediatric education or training have you received since nursing school?”

“I’ve taken a few pediatric continuing education courses.”

“Describe these pediatric continuing education courses, please.”

“I’ve completed a course in common pediatric diagnoses, and an overview of pediatric assessment.”

“Were these courses provided to you by your employer, Sand Bluff Hospital?”

“No. I took these courses on my own, as part of the continuing education required by the state of California to renew my license.”

“Has Sand Bluff Hospital provided you or other nurses in your unit with pediatric specific education?”

“Yes. All nurses assigned to the pediatric unit must complete age-specific competencies, and have current PALS certification.”

“And what is PALS certification?”

“Pediatric Advance Life Support.”

“Does this certification make you competent in the care of pediatric patients?”

“Objection!” This from the hospital lawyer.

“Okay,” says Grant, “Let me rephrase the question. What is the significance of PALS certification for nurses?”

“PALS certification signifies a nurse is competent in the necessary skills to assist in a pediatric code under the supervision of a physician.”

“But not specific to a particular diagnosis?”

“No. PALS certification is not specific to diagnosis. PALS certification outlines responses to specific patient conditions.”

“Like respiratory failure or cardiac arrest?”

“Yes.”

“PALS certification and, what did you say, age-specific competencies are provided to you by Sand Bluff Hospital, at their cost?”

“Yes.”

“So further pediatric nursing education regarding specific diagnoses is something, for the most part, you have taken on your own initiative, at your own expense?”

“Yes.”

“With no other education provided by Sand Bluff Hospital other than what you’ve just described?”

“Yes.”

“Melissa, have you reviewed the medical chart of the deceased patient from the night of the event”?

“I went to medical records and reviewed them once.”

Grant gives a sharp look to the other lawyer. I know what he’s thinking. This nurse isn’t the target of the suit, so no one’s taken time to prepare her for this deposition. That energy’s been reserved for damage control for the hospital. They’re the “deep pocket.”

“Melissa, tell us about that night, leading up to the event.”

 

It Happens (Niki sees in contrast)

Chapter 39

“Good work, Niki. Knowing the lab results and rash indicated a severe infection, yet this information was not reported to our client, Dr. Staid until after the boy’s death points the responsibility away from him, towards the nurse, and therefore at the hospital. That’s exactly the thing we’re looking for in the chart.

There’s an old saying among lawyers though, ‘Never ask a question in court that you don’t already know the answer to.’

So Niki, my question is: What difference would it have made in the patient’s outcome if Dr. Staid had been informed of the critical lab value and the rash sooner? Would the boy have received different care? Would he have survived?”

“I can’t answer that definitively, Grant. I mean, had the severity of the boy’s infection been diagnosed sooner, the shock that killed him would have been anticipated. Once the antibiotic came in contact with the bacteria in the boy’s bloodstream, the the bacterial cell walls burst, releasing their toxins and setting up a cascading circulatory reaction. That’s why the rash worsened from pinpoints to the huge purple blotches the nurse describes in her late entry note after the failed code. If this reaction had been anticipated, perhaps the boy would have been transferred to a pediatric intensive care unit where the technological support he needed was available, instead of admitted to a hospital unfamiliar with pediatric emergencies. Maybe he would have survived if that had happen. Maybe not. This kind of infection spreads like wild fire through the body of its host. Saving the boy’s life would have been challenging even for a PICU team. However, by the time they realized how sick he really was, it was too late. A small community hospital without a PICU couldn’t keep up. I feel bad for the family and for the staff.

As a nurse, Grant I have to admit I wonder why Dr. Straid didn’t come in to assess the child when it was decided to admit him? I know that happens a lot though. They leave it in the hands of the ER doc or a resident, and then see the patient in the morning. We have hospitalists where I work. A pediatrician is available both day and night.”

Mentally, I think of all of the times we’ve summoned Dr. Polk from the call room because a patient needed him.

“That question has been addressed,” replied Grant. “It’s our theme that, had he been informed of how sick the child was, he most certainly would have been at the bedside long before the code, when more treatment options could have been considered. The nurse did not inform our client of how sick his patient was in a timely manner, limiting our client’s ability to help the child.”

“Well, then you’ve got what you need, I guess.” Why does my stomach churn every time Grant and I reach this conclusion?

“Yes, and thank you Niki. We’re deposing the nurse tomorrow. Are you willing to sit in? I don’t want you to say anything, but maybe by hearing her deposition you’ll pick up on something else to strenghten our defense.”

The idea of being face to face with a nurse whose testimony I’m hired to shred makes me uncomfortable, but since I don’t have to ask her any questions, just listen, I figure it will be alright. I’m sort of interested in this whole legal process anyway.

“Sure. I’ll do that,” I tell Grant.

“Excellent,” he replies. “We meet in this conference room in the afternoon.

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.

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.”