The Wrong Side of a Sentinel Event Review (Niki empathizes)

Chapter 40

I woke up in Raquel’s and Grant’s guest room when a bright shaft of morning light slipped between the honeycombed shades and into my eyes. This never happens at home where I’ve installed black out shades in my bedroom, because I work night shift. My hand, tingly-numb from sleeping on it, reaches for and locates my phone on the nightstand. I check it for texts.

There’s one from the PICU manager asking if I’m interested in picking up an overtime shift. She doesn’t realize I’m out of town.

Next, Maddie’s sent a selfie of her and Wade eating hot dogs in Amber’s backyard after our phone conversation yesterday.

I’m disappointed there isn’t one from Corey. It hurts a bit, but I remind myself this is a tough time for him. Then I dismiss the matter from further thought.

After a serving a quick Raquel drops her kids off at school, we go to a cross fit workout at her gym. She’s is an animal, performing amazing feats with weights, pull-ups, and standing squats. I admire her “guns,” the well-defined muscles of her upper arms, noticeable in her tank top.

“Niki, you should work on your core. You’d gain a lot of strength with a little work,” observes Raquel.

“Maybe, but I rarely go to gyms. Don’t judge me. I like the outdoors, running or riding a bicycle. Maybe because hospitals are such closed environments. You are a lot stronger than me though.”

Afterwards, we stop for smoothies before going home. Then I shower, and borrow a pair of slacks and a blazer from Raquel, hoping I don’t look out of place at the deposition this afternoon.

Grant greets me in the conference room at his office building, fifteen minutes before the deposition is scheduled. We choose our places at the conference table, facing the door before the other nurse and her legal representative arrive.

“Thanks for coming Niki. I realize you hadn’t expected to sit in, but I think it will be useful to us. I don’t want you to say anything, just listen. Have you sat at deposition before? No, of course you haven’t, because I would have been there for you. Sometimes it’s good to have a lawyer in the family, right?”

“Absolutely Grant, I just hope I never need you. The long-term goal of my career is to never sit on the wrong side of a sentinel review committee.”

“Well, unfortunately, it happens to very good nurses sometimes. I’ve seen my share,” admits Grant.

“I guess I’m kind of feeling bad for this nurse I’ll meet today, Grant. I mean, good or bad aside, I don’t know anyone in health care who starts a shift thinking, ‘today I’m going to hurt a patient.’ People go into nursing to help others, not to cause accidental harm.”

“I understand, Niki. What you have to realize, is that this case isn’t really about placing blame on the nurse. What we want to establish is that an employee of the hospital, in this case a nurse, made a mistake contributing to a wrongful death, making it the hospital’s responsibility. Nobody is interested in suing the nurse. We’re defending Dr. Straid from being sued. He stands to lose a considerable amount of his financial assets. He has a couple kids in college, a house, and a business to protect.

Maybe the nurse won’t get sued, but she’s going to have to find a way to sleep at night for the rest of her life if she’s blamed for contributing to the death of a child, I think to myself. I keep forgetting which team I’m on.

“But Dr. Straid’s not guilty, is he Grant?”

“Of course not, the nurse didn’t inform him of how sick the boy was. The hospital is the deep pocket here Niki, not the nurse. A patient should be safe in a hospital, right?”

“Yeah, you’re right, Grant. Patients should be safe in any hospital.”

“That a girl. Now, here comes the nurse, and the hospital lawyer. Remember, don’t talk just listen.”

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.”

It’s What I Want (Niki gets a phone call)

Chapter 35

 I’m happily vacuuming my living room, thinking about a conversation Corey and I had last night during a quick break at work.

“Sheila was really calm when I told her I want a divorce. I think it’s all going to be okay. She isn’t happy either. We agreed she and the girls will live in the house, and I’ll get an apartment. Sheila says she’ll let me know what else she wants after talking with her lawyer. I’m okay with that. I just want out, and shared custody of our girls.”

“This is happening so fast, Corey. You’re sure this is what you want?”

“It’s what I want. I can’t wait until we can let everyone know we’re in love. You still want it too, right Niki?”

“Yes, it’s what I want.”

We’re in love. I just have to be patient a few more weeks. Jumping ahead, I wonder if it’s better to introduce Maddie to Corey at a restaurant, or a quiet dinner here at home? I wonder what his daughters like to eat? I wonder if either of them have food allergies? I make a mental note to ask Corey.

The phone rings, startling me out of my daydreaming. There’s a ping of anxiety in my stomach when I see it’s Corey. He never calls in the middle of the day. Then I remember he’s told Sheila he’s leaving. It’s okay. We don’t have to hide anymore.

“Hey! What’s up, babe?”

“Um Niki, I can’t talk long. I’ve got something to tell you,” his tone is serious, and then his voice breaks. I can tell he’s on the verge of sobbing.

“Corey, what is it? Are you okay? Are your girls okay? What’s wrong?” He inhales deeply before speaking. “It’s not me or the girls, Niki. It’s Sheila. She found a lump in her breast. We just came back from the doctor’s office. It’s cancer. Sheila has breast cancer.”

“Corey, I’m sorry. That’s terrible. How’s she’s taking it?”

“She’s upset, of course, but otherwise taking it pretty well. We won’t know more until we see the oncologist. They have to run more tests. We haven’t told the girls yet; we want more information first. I’m taking her to the appointments, and helping her ask questions of the doctors, finding out her options. I’m on stand by for now, Niki.”

“I understand, Corey. Do what you have to do, and keep me updated.”

“Thank you Niki. I will.

“Let me know what I can do to help.”

“I gotta go. I love you Niki.”

“I love you too, Corey.”

After Corey hangs up, I finish vacuuming, no longer worried about introducing him to Maddie for now. My emotions are jumbled: guilt, and concern for Sheila, disappointment that Corey’s and my plans are on hold. I hear my mother’s words from childhood, “Don’t count your chickens before they hatch. Don’t get your hopes up about things before they actually happen, you’ll always be disappointed.”

Maybe if I were more spiritual, I’d consider this Karma. Maybe I’ve attended too many pediatric deaths to believe. Maybe I’m too numb to know how I feel at this moment: There’s sadness, and guilt, for sure, but deep down inside, unexpectedly I detect a small amount of relief too.

You Do Important Work (Niki Makes a Purchase)

Chapter 32

The photo shoot progressed in ‘hurry up and wait’ format.

We patiently stood in front of the camera while lights were adjusted, and the angles of our faces repositioned, dressed in brightly colored scrubs, with improved, professionally applied make up. Even the male nurse’s eyebrows were shaped with pencil, and he had concealer applied to blemishes.

We held “nurse props” like stethoscopes and clipboards in the photos. While a light above my head was adjusted, it dawned on me that we could easily be a group of dental hygienists or veterinary technicians instead of nurses. Although nursing science has burgeoned, the visual cues of traditional white caps and uniforms remain iconic. Instead of standing out visually in clinical settings, as in the past, modern nurses blend into the melee of scrub attired workers. Is there a similar icon for physicians? All I can think of is the old-timey black medical bag of the past century. I’ve never actually seen a doctor carry one, and they don’t recur in popular imagery like the nurse’s cap.

I’m snapped back into the present by Todd. “Niki, look into the camera and smile for me, okay?”

At 1230, we’re given a lunch break. The table in the back of the room holds stacks of white boxes.  They contain sandwiches, salads, and a cookie from a catering company. I choose one. Todd taps my shoulder.

“Hey Niki, mind if I eat lunch with you so we can catch up?”

Todd and I carried our boxed lunches outside, and sat on the cement edge of a large fountain in front of the convention center.

“I’m impressed you’re a professional photographer Todd. I remember you as a nice guy taking photographs for the high school yearbook, and newspaper. How did you end up doing it for a living?”

“You mean you remember me being a camera geek using photography as a way to meet pretty girls on campus, but I appreciate your rendition. Actually, after high school I travelled around Europe, and stumbled into a job with a modeling agency. They were looking for American models for a company selling jeans. It was fun, but I like being behind the camera more than in front of it. So I got a job as the assistant for one of the photographers. After I returned to the States I started out like most freelance photographers, shooting weddings, taking graduation pictures, that stuff. Then one of the models I met in Europe, Maggie, asked me to do her wedding. Her father’s a big time publisher, and I met a lot of editors at the wedding. I started getting calls, and here I am. I got lucky. What about you?”

“My story’s not as exciting as yours. I went to college, became a nurse, got married. I have a fabulous daughter. I’m divorced.”

“What kind of nurse are you?”

“A good one, I think. I work in pediatric intensive care.”

“Oh wow, with all of those little preemies?”

“No, that’s neonatal intensive care. Sometimes my patients are premature, but mostly they’re newborn up to age eighteen. They have serious infections, surgeries, or are trauma victims. Most are on ventilators for at least part of their hospitalization.

“Wow, I couldn’t work with sick kids. It would break my heart. You do important work.”

“It breaks mine once in awhile, for sure. I always wanted to take up photography though. It must be great to make money doing something you love.”

“It’s like anything, really. I’m hired to produce specific work. It depends on the look the publication wants. The creativity is discovering my unique way of seeing it. I do fine arts photography on my own time. I have work in a couple of galleries.

“I would love to do something creative. The only photographs I take are with my phone.”

“If you’re serious about photography, I just upgraded to a new camera. I have a used kit I was dropping off at the photography shop to sell on consignment. If you’re interested, I’ll give you a good deal. The kit’s complete, lens, bag; the owner’s manual is there too. I can get you started using it today. You can text me with questions as you go along.”

Lunch was over. Todd and I returned to the shoot, which lasted the rest of the afternoon. Standing under the lights, I felt expansive, imagining all of the photographs I will take.

After the shoot, Todd explained the camera, and its accessories. He gave me a really great price, I think. To be honest, I don’t know a lot about cameras.

But I bought it anyway.

Buy Yourself Another One (Foraging for food on night shift)

Chapter 27

While getting ready for work I struggle over wearing my hair loose around my shoulders, foregoing the usual scrunchy-bound topknot I wear when I haven’t bothered to wash it.

“Pull it together, jeez,” I reprimand myself. “He’s still married. Don’t set yourself up like this.”

Pulling into the staff parking lot, I look for Corey’s car, but I don’t find it. He may have parked elsewhere, because there are never enough close-in staff parking spaces. I unwrap my stethoscope from around the rear-view mirror, grab my tote from the passenger seat, and breathe deeply to calm my giddiness before entering the hospital.

“Jeez-us, you’re a grown woman. Calm down,” I repeat, but the butterflies in my stomach still flutter.

Corey catches me at the elevator just before I head up to the PICU. He’s holding a little pink bakery box.

“Hey, I brought you a cupcake for your break tonight. I’ll stop by if it’s not too crazy. You’re hair looks nice down.”

I take the box, hoping he sees how happy this makes me before I recover my normal expression and say, “Thank you.”

Corey waits in front of the elevator until the doors close and I am out of sight.

As it turns out, Corey’s gift of a cupcake is prescient.

***

One of the problems of nightshift nurses is foraging for food.

Budget cuts have limited hospital cafeteria hours, leaving nightshift without options besides bringing their food or snacking from vending machines. Occasionally, nurses will send a “runner” to an all night fast food place to pick up dinner for several coworkers, but that only happens if the department can spare the nurse. This was not one of those nights.

In the PICU all Hell broke loose.

The kid in bed two continually seized despite being in a medically induced coma, and no one knew why. This kept Kathy busy with frequent lab draws, adjusting drips, and administering anti-seizure medications, all the while trying to comfort distraught parents, and documenting the frequent changes.

Liz’s hands were full with a post-open heart surgery patient whose blood pressure repeatedly tanked in room five. She also had a second post-open heart patient weaning off of sedation in preparation for extubation from the ventilator in the morning; the short of this being that she had to keep that child from pulling out his breathing tube and IV’s while allowing him to breathe on his own.

And me? I was managing a new onset diabetic admitted on dayshift with a blood sugar of 400. This meant frequent blood draws for lab values, and several changes of IV fluid solutions, lowering the potassium as the insulin drip took effect, and the blood sugar normalized.

This did not prevent me from being up for the next admit, however: a stable neurology patient accompanied from the OR at midnight by his neurosurgeon, Dr. Kearney. The boy had an infected shunt, a surgically implanted device that drains excess cerebral spinal fluid from the ventricles in his brain, caused by a congenital condition. The infected shunt was removed, and a temporary external one now drained CSF through a tube into a buretrol. IV antibiotics were prescribed around the clock. Once the infection healed, the neurosurgeon would replace the implanted shunt with a new one in the OR.

Dr. Kearney sat at the nurses’ desk, calling lab for culture results, and entering orders. I overheard him saying into the phone, “What do you mean I can’t order ‘antibiotics per pharmacy protocol’?” There was a pause. “Well why isn’t there an ‘antibiotics per pharmacy’ protocol?”

Shortly before Dr. Kearney’s arrival, Liz had sat in the same seat at the nurses’ desk in which he now sat. In front of him was a small open bag of potato chips belonging to Liz, which she’d momentarily left unattended to answer an alarm in her patient’s room. She hadn’t had time to pack a dinner, and this bag of potato chips from the vending machine represented the only food she would probably eat tonight.

When she returned to the desk, the bag of chips was empty, and Dr. Kearney brushed the last crumbs from his mouth.

“What happened to my bag of chips?” demanded Liz.

“Oh, were those yours? I thought they were out here for everybody,” Dr. Kearney was unapologetic.

“That was my dinner,” growled Liz. “Now what am I going to eat?”

Dr. Kearny said, “Here,” and tossed a couple of dollar bills into the empty bag on the desk. “Buy yourself another one.” Then he left.

Liz returned to the PICU ranting. “The damn vending machine ate both of Dr. Kearny’s dollar bills without giving me a bag of chips, even after I kicked it!”

Kathy and I shared our food from home with Liz, and I divided Corey’s cupcake three ways.