She was killed by a conspiracy of circumstances.

Early in my career, I worked in the U.S., in a teaching hospital in a midwestern city. The hospital was authoritarian in its management. Policy and procedure was centrally dispensed. Nurses had little, if any, control over their practice. All the hallways, without exception, were painted a rigid, unrelieved white — the hospital’s “colour” — as if to symbolize this authority. Morale was dismal. Teamwork was non-existent.

The Emergency Department in this hospital consisted of three “pods”: three nursing areas, each in the shape of a square, sixteen beds in a pod, all monitored beds, a nursing station in the centre. There was a Trauma Room in one of the pods, but otherwise, patients went to beds undifferentiated in acuity or complexity. New onset strokes lay beside fractured femurs who lay beside minor lacerations who lay beside the intubated head injuries.

Three Registered Nurses were assigned to each pod. They were assisted by an “ER tech” who did ECGs and other scutwork, a housekeeper, and by a ward secretary whose only job (it seemed) was to answer the phone. All the RNs, save for two, were white; all the housekeepers and techs were African-American. Working at this hospital was an education in American race relations and racism.* The tension was nearly visible at times. Moreover, on any given shift, two or three agency nurses of uneven skill were on the roster. The hospital administration had decreed, as a cost saving measure, these agency nurses would not be paid for missed breaks. No matter what the condition of the department, therefore, the agency nurses could be depended upon to take their breaks.

The night the patient died, I was in Pod 2. It was busy. I had five patients in beds, including an intubated CHFer and a restrained psych patient needing checks every fifteen minutes. As a sort of bonus, I also had a patient in the hallway in front of the nurses’ station getting intravenous hydration before discharge. I was working with Janet, one of the two black nurses, an old hand at emergency practice, calm and collected, and Christine, an agency nurse, a regular, fiftyish, with a superfluity of jewellery. They had equally heavy patient loads: Janet, in particular, was kept busy with a stabbing (minor lacerations) and a restless Alzheimer’s dementia waiting for a bed upstairs.

Around 2030, Janet got a new patient, a 39-year-old patient with cough and increased shortness of breath, with a history of insulin-dependent diabetes. Her husband and her two teen-aged sons accompanied her, the elder of which had just come from football practice: he was still wearing the green-and-white uniform of the local high school. When I walked by her cubicle, I looked in: she looked unwell, pale, diaphoretic, her hair hanging in dark strings from her forehead. Janet assessed her, put the chart up for the physician to see; she then reported off to Christine, and went to break. I asked Christine about her.

“She’s probably a pneumonia,” Christine said. “She’s known to us. Her vitals are stable, her blood sugar is okay. She been here before with the same.”

While Janet was on break, the physician saw the patient, and she ordered a cardiac work-up, in addition to the usual sepsis blood work. This included an ECG. The usual practice, once the requisitions were filled out, was to delegate the ECG to the ER tech; if the tech wasn’t able to do the ECG, the responsibility fell back to the nurse. Christine said later she asked the  ER tech to do the ECG, but the ER tech promptly went to break. The ECG wasn’t done.

Just afterwards Janet came back from break. By now it was hideously busy. But Christine reported off to me, meaning to go to break; she wasn’t, she said, about to sacrifice herself because of a “stupid hospital policy”. She neglected to tell Janet about the physician’s assessment of her diabetic 39-year-old, nor about the orders. The ECG still wasn’t done. In any case, Janet’s dementia patient had fallen out of bed, she was incontinent; there was a mess of stool and urine. I went to help Janet.

Cleaning and resettling the dementia patient took some time. When we came out again, it was nearly 2245. Christine was back from break, charting. I glanced at the cardiac monitors. The diabetic’s heart rhythm, the morphology, was abnormal.

“Your diabetic lady,” I said to Janet. “It looks like she has ST elevation.”

“I thought the rhythm looked a little weird before I went,” said Christine. “I wondered if something was going on.”

At that moment the ER tech came trundling up with the ECG machine. The ECG still hadn’t been done.

“Fuck,” Janet said.

We paged the physician overhead, ran to the diabetic patient’s bed, did the ECG. Her sheets were soaked from sweat, and we had difficulty placing and maintaining the electrodes on her cool, wet skin. There was enormous ST elevation in the inferior and lateral leads. She was having a heart attack.

The emergency physician came. Soon, the cardiologist came down, and we were prepping the patient for the cath lab. Two IV lines, antecubital, high flow oxygen, consents signed. Her husband and sons were asked to go to the waiting room. Her blood pressure bottomed out; we bolused saline and hung dopamine. She went unresponsive, and the monitor showed ventricular tachycardia. She was pulseless. I started compressions and someone called a code. We defibrillated. Her rhythm went to ventricular fibrillation. We shocked again. Asystole. No electrical activity in the heart. We pushed drugs, epinephrine and atropine, did chest compressions. Asystole. After a half hour, her skin was mottled purple on her trunk and legs. The cardiologist called off the resuscitation. She was dead. The cardiologist remarked, in an almost off-hand way, that her death was unnecessary. A little while later, hospital administration arrived. The death, in that grotesque hospital-speak, was a therapeutic misadventure, a sentinel event. Janet faced an inquisition over her care: clearly, from the hostility of their questions, they were looking for a scapegoat.

If you want a proximal cause, the patient died because the ECG wasn’t done promptly. It is true too that Janet neglected the red flag of the patient’s diabetic history, both increasing the risk and concealing obvious symptoms of a cardiac event. The patient had no overt chest pain; she didn’t present as a heart attack. The hospital administration used these as grounds to fire Janet, even though the lack of an ECG was not really her fault: she was still ultimately responsible for the patient. But like most sentinel events, the real reasons for the patient’s death were more complex. There were circumstances. The lack of teamwork, poor morale, hospital policy regarding breaks, the inadequate staffing, the design of the department, the patient flow and assignments, the use of agency nurses, the high levels of patient acuity and complexity when the patient arrived in the department, the lack of clear policy around ECGs  — all of these conspired to kill the patient.

As for me, I went home and intentionally got drunk for the first time in my life. I felt as though I had personally killed the patient. When I walked by the patient and glanced in, I knew she wasn’t well. Should I have intervened more directly? It’s a question which has haunted me since. I don’t know the answer. But I have never walked by such a patient since without ensuring to my own satisfaction their care is appropriate. There was one further consequence for me: a week later, I resigned and came back to Canada.


*A Filopina RN, a recent arrival to the U.S. and someone who I was quite friendly with, said to me one day, “This hospital does not like brown people.”


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  1. #1 by Joni Watson on Friday 01 October 2010 - 1238

    Our recent posts align. I hear ya. I feel ya.

  2. #2 by NNR on Friday 01 October 2010 - 1531

    Firing the nurse is just not the way to keep this stuff from happening…systems problem systems problem systems problem. I’m always repeating myself here. I feel like getting drunk after work a lot too, but I don’t. Instead I let this stuff eat away at me bit by bit and develop deep resentment about a SYSTEM that allows healthcare workers to work as hard as we do and then fire us when we make mistakes (many of us, along with the SYSTEM problems that allowed the overcrowding, etc.). Stories like yours make me sad.

    • #3 by torontoemerg on Friday 01 October 2010 - 1650

      You know, when I got seriously drunk, I did some serious thinking — which is why I quit. I just wonder how many would stay… and drink. ..

  3. #4 by nurseXY on Friday 01 October 2010 - 1643

    Wow. I’d like to think that would never happen today…but…

    To me, a well known patient is a dangerous patient, because we all let our guard down.

  4. #5 by Jenn Jilks on Friday 01 October 2010 - 1729

    These are all lessons. You write with passion and honour the patients. We make the best decisions we can at the time, with the information we have. I’m glad you are in Canada!

  5. #6 by The Nerdy Nurse on Friday 01 October 2010 - 1955

    this is sad on so many levels.
    I feel so terribly for her family and how horrible it must have been for them to watch their mothers life slip away in front of them.
    I am so discusted by the lack of teamwork. No one person can do everything, especially when those in power are breathing down your throat in order to save a buck. That $10-30 they saved by forcing someone to take a break, is pathetic. Someone who was needed in this world, who had a family that needed them, lost their life because someone wanted to fatten their already thick wallet.
    I am so sorry that you had to witnis this event, but I am glad to have heard it from you. This is a good reminder that all patients we come in contact with are owed a second look, and for our actions an words to make a difference for them. They come to us asking for help, and we need to give it as a team, and as quickly, efficiently, and kindly as possible.

    thank you for sharing this with us.

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