“A Dios mio! Pain! Pain!” I heard  the woman’s cries all the way down the hall as she was led by the ED tech to my last empty bed. I sighed and took the chart from the tech. 60 year old woman with a three day history of left flank pain. “OK” I thought, this should be easy.

I went in to see her, and introduced myself.  She was tiny, barely 5 feet tall, her graying hair held back in a bun. She told me her name was Sonya and that her doctor had diagnosed her with kidney stones at one of the other local hospitals. She’d decided to come here because “they don’t give me any help.”  I had her put on a gown, started an IV and drew labs, and instructed her to give me a urine sample. “Thank you thank you,” she said in breathless, broken English. “The pain is very much worse.” I smiled and pointed her to her bathroom. She patted my hand before heading that way.  I am always a sucker for the older patients.

In the meantime I checked on my other patient in the same room. David was a 30 year old “frequent flyer” who came in via EMS writhing in lower abdominal pain; he was going to be worked up for possible appendicitis, even though he’d presented five times this month already with similar symptoms. His tests had come back negative each time, and the doctors were starting to suspect he might be a drug seeker. David was resting comfortably, having received a morphine and phenergan IV cocktail.

I could tell when Sonya was back to the room by the progressive moans and groaning she made as she ambled back from the bathroom. I helped her into her bed and assured her we would make her as comfortable as possible. I told the ED resident that Sonya was in a lot of pain, and that she was ready to be seen.

Next I saw David’s call light go on and when I went in to check, he told me that the pain was back again, and he asked for more morphine. The pain was rated a 10/10 and he curled up on the bed holding his abdomen. I remembered his last visits, which were the exact same presentation but nothing was ever found on CT. I looked at the clock; it had only been 45 minutes since he’d received the morphine. I tried repositioning David to find a more comfortable position but it was useless. He was in pain no matter what position he was in. I asked the resident for another order of morphine and she wrote it with a sigh, mentioning that it seems David had increased his visits lately and maybe it was time for a psych consult.

 The resident saw Sonya while I prepped David’s morphine.

When I took the medication back in for David, Sonya saw me and started moaning again. “Is that medication for me?” she asked. I told her I was sorry, it wasn’t, but that I’d have some as soon as the doctor ordered it. She looked so small and alone in the bed. I brought her an extra blanket. I quickly obtained the order and administered Sonya some morphine. She lay back happily.

Shortly, both patients were transported to CT. I went about my shift caring for my other patients.

A half hour later, after both of the patients had returned, “Look at this” the Dr said, indicating her computer screen. Sonya’s CT was perfectly normal, no evidence of kidney stones.

“And this too,” the resident said, changing computer screens. Sonya’s history came up on the screen; she’d had 15 visits in the last 2 months, all with pain. Futhermore, her history indicated a continuous use of street drugs.

The resident sighed and was about to get up and go see Sonya when her pager went off. She returned the call and turned to me. “David’s got a hot appendix. He’ll be going to the OR within the next half hour.”

As I sat filling out the pre-op paperwork for David and listened to the resident as she attempted to explain to Sonya that there was no evidence of kidney stone and that she would not receive any more morphine, I sighed. In this business, it’s so easy to gain preconceived notions and ideas. This was a good night to remember that nothing is ever necessarily just what it seems.

As I sit here tonight, thinking about my new job and all the new things I will see and learn….I start looking back to the time before I was a nurse, before I’d had this training and this knowledge base. Going to nursing school, graduating with good grades, and doing it all while raising two kids and having a husband who’s health is sometimes a question mark.
I followed a home care nurse around the worst parts of the city and into roach-infested apartments. I stood for 8 hours in a freezing operating room, watching gallbladder after gallbladder come out.  I suctioned trachs, flushed IV lines, gave shots and pills, fluffed and turned. I changed elderly adults soiled briefs, cared for people with ORSA, MRSA, VRE, scabies, lice and C-diff.  I did psych where the patients scared the hell out of me. In maternity I saw babies born. This was all stuff that I never dreamed I would be doing.
And I learned. Like a sponge, you learn to soak it all up. Don’t miss anything and write it all down. You never know what will show up on the next test. And then the final exam of the final semester comes almost before you know it. Dread and trepidation keep you up at night, along with the thought that if you don’t know it by now you never will. That final time you close your textbook and put away your notebook…you sigh and leave home for the final exam.

They were still giving out the grades immediately when I took my final. That was the last time they did it. I was the first or second person done with the test. I looked around the room, not believing that I was actually done. I didn’t check my answers. You learn by the middle of the first semester to go with your gut, and take your first answer. It’s always the right one. It was a 100 question test. When I finished I took my test up. I passed! I was done. 
I. Finished. Nursing. School.

I hugged the instructors and danced out. Apparently someone after me did not pass, and either fainted or freaked out (depending on who is telling the story) and now no one gets their grades in the test room. Now they all have to wait 24 hours until the grades are posted.

Pinning came a week later, and the ceremony was great. There was a slide show, and awards. We were each pinned by a member of the faculty, and then we took a class picture. 77 of the original 99. Not too bad.
 
And then there was a huge moment of nothing….I had this sinking, lost feeling. School was over. I’d graduated.  And I had nothing to do for two weeks until my new job started.

I felt lost while. I don’t know why. I had a couple weeks of just being ahead of me. No studying, no getting up at the crack of dawn for clinical, no tests. It was odd. I slept a lot. Probably a minor depression. On one hand I was glad for the rest, on another, well, I wanted a party or something. 

So I bought new wall-to-wall carpeting.

A page from Deanna’s Journal

Last night I was waiting for my patient to return from Xray confirming his epiglottitis. (Major stuff. Could lead to death d/t airway closing up). The Dr. had his results already and the pt was going to be admitted to the acute ED and from there to a critical floor. Note, he was awake, talking and not acting as if he was about to stop breathing BUT, with the swelling of the epiglottis…it can (and does) become an acute and critical situation very quickly.

The patient returned from Xray in a wheelchair and was wearing a surgical mask. He was put in the reception room, where there were a couple of our other patients as well. I knew he had come back because the transportation tech told me he’d put him there. The Dr. looked through the reception window at him and said “Good, he’s back. Here are the orders. ” (IV, lots of labs, blood cultures, NPO status, and an antibiotic shot)

In our ED, we have a program where med students are available to “line and lab” patients in order to give them hands-on experience. I got the supplies for the IV start and labs, and some labels to both identify the patient and to label the blood samples and went to get the patient. I saw through the window that another med student was already lining and labbing him. “Ok, that’s weird” I thought, since I had the order sheet in my hand, and as far as I knew, no one else knew what he needed.

The patient had a big surgical mask on, all that you could see were his eyes. I had only seen him briefly before, so I didn’t really know what he looked like. I went and asked the med student if this was Mr. Jones. “No, this is Mr. Smith” she said as she worked on starting the IV, and pointed to the gentleman’s med sheet on the table next to her. Indeed the med sheet said Mr. Smith.

Hmm…. Maybe I was wrong and Mr. Jones wasn’t put in reception. I looked in each exam room, and found no Mr. Jones. I asked the other nurses if they had seen Mr. Jones? No one had seen him. During this time, the med student was still in reception working on “Mr. Smith”. Finally I asked the Dr. if he’d moved the patient somewhere else. The Dr. said “No, he is right there” pointing through the window at “Mr. Smith” and the med student. I went back to reception and looked at the patient’s wristband. Sure enough, it said Mr. Jones. I asked him to verify his birthday and his last name. This patient is truly the elusive Mr. Jones, and not the Mr. Smith that the med student thought she was lining. The med student looked like she was going to faint. I told her it was fine. Mr. Jones needed the line and labs, just finish and not worry.

If only it had ended there. I picked up Mr. Smith’s med sheet and left the correct one, the med sheet for Mr Jones. After I walked out of the room, I saw that a medication on Mr. Smith’s med sheet had been signed off by a nurse as having been given to Mr. Smith. This normally would not have alarmed me, EXCEPT it was given during the time that the med student (and presumably the other nurse) thought that Mr. Jones was Mr. Smith.

I located the nurse who’d administered the medication. She said “What do you mean that is not Mr. Smith?” We rush back to the patient and the med student. The other nurse said “You aren’t Mr. Smith?” Pt says “Why no, I’m Mr. Jones.” Another pt in the rooms says “I’m Mr. Smith.” The nurse now looked like she might faint. I took her out of the room. She did, in fact, give the wrong med to the wrong patient. Luckily the med itself wasn’t a huge issue. It was ibuprofen BUT, the wrong patient got it! More importantly, the patient who is supposed to have nothing by mouth because of the risk of throat swelling and occluded breathing, was given a pill. To swallow. The med student looked like she was going to cry. Both men needed lines, so that was okay. But, if she’d succeeded in obtaining the labs before the mix-up was identified, she would have sent the wrong labs on the wrong patient with the wrong labels and it could have been bad. She didn’t. So count that as a near-miss. Now the nurse in question… she gave the wrong med to the wrong patient. Not a near miss. A real med error. If that nurse had taken the 10 seconds to look at the patient’s wristband and verify he was who she thought he was…it would not have happened. But she didn’t and so it did. All were wrong in this case. The nurse in question got lucky… the patient did not have an adverse reaction, but the potential was there. Know your patient, and verify their identification EVERY TIME. That nurse and patient got lucky. That may not be the case next time.

Remember:
Right med
Right patient
Right dose
Right route