I’ll never forget…

Although this happened a few years ago, I still get chills whenever I think about it.

I was working as charge nurse on our small (13 bed) post-op unit. My coworker Lisa and I were the only two nurses on the floor because we only had 8 patients. One more patient and we were allowed to call in our coworker Jackie, who was sitting at home on call. Around 8 pm the pager went off alerting me that we were getting a new admission– a post-op hemorrhoidectomy patient having severe pain. Her surgery was scheduled as outpatient, but she was being admitted for pain control. My patients weren’t too difficult, and Lisa had things under control with hers as well, so we debated if we should call Jackie in or not. I called Jackie to see if she wanted to come in, and after some debating back and forth, she decided to come in instead of getting called in the middle of the night if we got another admission.

The patient arrived on the unit before Jackie arrived, and I did her initial assessment and took her admission history. I remember feeling silly asking if she had a living will– she was there for a hemorrhoid removal.  She was in pain but her medications still weren’t in the computer from our pharmacy yet, so I had to wait before administering anything.

Jackie arrived right as the pager went off with another admission, so I let her choose which patients she wanted. She chose the new admit and the hemorrhoidectomy patient. The patient’s medications finally showed up in the computer, so Jackie went in to give them.

She gave the woman some IV medication for her pain, which is when I would have left the room had I still been her nurse. But since Jackie needed to do her own assessment, she began taking the woman’s vital signs. Temp was normal, heart rate was ok. She put her stethoscope on the woman’s chest and said “Take a deep breath.”

The woman didn’t take a deep breath. Jackie waited a few seconds, and the woman didn’t take any breaths at all. She had stopped breathing. She called the woman’s name, shook her shoulders– the woman was unresponsive.  Jackie started yelling for help, which I heard from down the hallway. Lisa and I both ran to the room. The woman’s bed was in a sitting position but she was slumped over. She had no pulse. I hit the Code Blue button and ran to get the crash cart while they lowered the bed and began CPR.

It felt like it took forever for the code blue team to arrive. Once they did, it took over ten minutes to get a pulse back. She was transferred to the ICU where she ended up being ok.

Jackie had done nothing wrong- the woman had a severe reaction to the medication, causing her heart to stop. I couldn’t (and still can’t) stop thinking about what would have happened had I kept that patient. I’d already assessed her, so I would have left the room. When I went back ten minutes later (or longer, depending on if I got tied up in another room), I would have found my patient dead. I don’t think I ever would have recovered from that. What if Jackie had decided not to come in? Or had she picked a different patient to take over? Or if the medications had been in the computer earlier?

All I can say for sure is that someone had a guardian angel paying attention. I don’t know if it was mine or my patient’s, but I am forever grateful.