S o I’m driving into work and in the parking lot a guy waves to me that I don’t know. He looks a little frantic, and not very employed, and my initial impression is to ignore him. But his waving becomes even more frantic and I’m going to have to drive right past him anyway as he is walking to the Emergency Department via a path that crosses our parking lot. So I give a small wave from out my window. He doesn’t approach but instead calls out, “Your lights are on!” It’s 6 pm on a summer day, and it won’t be dark for 3 hours. I give a side smile, attempting to cover the competing embarrassment of having left my lights on, and even having this conversation in passing as I head to work.
A t my lunch break, I walk up to the coffee shop just before they close for the night. Carla has become a good friend across the counter, as the frequency of our interactions has solidified our friendship. She knows I want a large blended coffee with 3 extra shots, and I know she is finishing massage school and is feverishly working on her novel for NaNoWriMo. She trades my coveted “afib with whip” for a 5 dollar bill and motions to her mouth. I stop my story of how my coworker just made our night by recognizing Tako-Tsubo Cardiomyopathy and lean in. She is gesturing to her upper teeth discretely, trying to no draw attention from the crowd of hospital employees salivating behind me for their own caffeine fix. “ You have something in your teeth,” she said. I quickly start picking at my teeth in the area she gestured to and I pull a huge green spinach remnant from my pre-work meal before I left the house. “Thanks,“ I say as I head away from the counter. “Good lookin’ out.”
W hen I get back to the floor I am called into my manager's office. I’m barely 4 sips into my coffee, so I make sure my name is on it before I abandon it to the wolves in the break room to see what my manager wants. We sit down and he starts out with, “This is not going to be a disciplinary action, but we need you to correct your charting.” Yesternight, I had a very busy team. Has that ever happened to you? So I had this busy group of patients and one patient, in particular, was in extreme distress. I was giving pain medication and titrating sedation and drips all night. The new rules in our hospital state that I need to have a complete pain assessment, a pain scale, and a RASS assessment with each med and titration, and a reassessment within 30-60 minutes. I gave or adjusted medication for sedation and/or pain over 30 times in 10 hours. Needless to say, I missed a few documentation items. I was raised in medicine in a time when charting was considered secondary to patient care. The papers can wait, the patient can’t. However in today's electronic charting world when a chart audit can be flagged automatically, my fate was sealed when I was still eating my spinach and chicken this evening before work. Staying after on a shift to finish charting is “Not a valid excuse for incremental overtime.” So here I am being told I did something wrong for the company, even though I did right by the patient. Thankfully my rapport with my boss was still intact, and I was given the opportunity to correct the charting, “Before Midnight.” so that another audit isn’t flagged.
I returned to my now melted coffee. The condensation running down its soft plastic body reminded me of how much sweat at the gym this decision was going to cost me. But that guilt quickly left as the chocolate flavored rocket fuel slid into my belly, and all was right with the world again. Returning to my charting, a coworker walked up.
D an is a strong nurse, been on this floor for 4 years but had spent 10 years before that at places like Stanford and UC Davis. He is applying to a masters degree program somewhere and was my preceptor on this floor. His energy is a little surprising as he quietly presses, “Dude, did you hear about what happened to that patient last night?” His intense stare concerns me and I say I haven’t heard anything. He shakes his head and says in a quieter voice, “Dude, he’s dead.”
T his patient, let's call him R, was the kind of patient that wears down staff before they finish their first assessment. A longtime drug user, his street life had destroyed all of his relationships and connections. His habits brought him to the hospital yesterday for the last time.
M y report on R included that he was here for a GI bleed, had a new diagnosis of cancer, was a longtime drug and alcohol abuser, and was a complete and total asshole. When I got him to my floor, he did not disappoint. He was vulgar, insulting, and extremely demanding. And that was just the first 3 minutes. But I had prepared. I knew he would be tough, and I was going to give him the respect and dignity and compassionate care that no one else could. So when he released a horrific bowel movement of blood, I was right there to clean him up. New gown and sheet and fresh warm blanket. I finish my assessment and before I leave the room he again has a bloody stool. I clean him up, change everything, new warm blanket. I went to get his meds and when I came back he again had a bloody bowel movement. But I’m committed to making sure I treat him with dignity and respect, so I don’t even hesitate. I clean him up, change everything, and give him a fresh warm blanket. He came to me at 2 am, and I cleaned him no less than 5 times before 6:30 when I started to get ready to give report. The oncoming nurse notes that the am labs look like he’ll need a transfusion. There is also a plan to send him to nuclear med for a study to find out where he is bleeding. I wished the nurse good luck and sauntered off to my car feeling like I had done a great job taking good care of this patient.
T urns out that the patient with bloody poops was actually bleeding out. That patient needed a transfusion on my shift, not hours later on day shift. When they went to order the blood, there was a delay of several hours because of R being a cancer and chemo patient. The blood had to be specially processed to be safe for his near non-existent immune system. R was in a bad way, and when they sent him to Nuclear Medicine to try and stop the bleeding, he coded and died.
I thought I was taking great care of my patient by giving him the respect and dignity that no one else was willing to. But it turned out that I was failing to anticipate the medical needs of R. The lesson R taught me was one of the most profound experiences in my career. People do not come to the hospital for respect and dignity. People come to the hospital for medical care provided with respect and dignity. What good is holding a patient's hand and listening to their story if you are neglecting to address the medical needs?
D an and I discussed the case at length. There were follow up conversations with my director and educator in the following weeks. I was written up. I would like to say that it was an educational experience but instead I felt bullied and abandoned by my management. If you work in a place where your mistakes are treated as learning opportunities, be reminded that this is exceedingly rare and you are super lucky. If you work is a place where mistakes are treated as punitive lashings, this is normal and you are not special. Though I should have done more for R, I was not negligent as determined by my management. The advanced state of R’s condition would have most likely lead to the same end, even if I had started those blood transfusions earlier. The write up was for my failure to alert my shift supervisor that the patient was becoming more ill. But nothing would weigh as heavy as my own guilt for missing the mark.
B eing called out for a mistake, be it minor or major, is never a comfortable thing. The source of that strain and anxiety is the lack of trust in the person calling you out. When a friend points out that I forgot to label my IV lines, I can take that correction in two ways. Are they saying, “You made a mistake because you aren't good at your job.” or are they saying, “I caught this mistake because we are all looking out for each other and I hope you find my mistakes.” In a disciplinary situation, it is very hard to take correction, as opposed to an educational situation. If you can grow your own self-perception that you would be a student of life, then you can leave your ego at the door and take correction as education more often than not. When a person catches you doing something wrong or not well enough, that is your opportunity to improve. If no one notices your mistakes then how can you grow? Or worse yet, do you think you are the kind of person that doesn’t make mistakes? Get comfortable being uncomfortable, including receiving correction. People of all levels, experience, and social strata can see things that you can’t. By letting yourself learn, only then can you become more. Who knows, maybe one day a drug-addicted and homeless asshole will teach you how to be the best provider you can.