Mood:
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Now Playing: 'Cherish The Day' by Sade
Some days, I wonder if nursing school is right for me. I know we all get frustrated with what we do, and that the things worth having aren't easily attained. But some days I just feel like the shit isn't worth it, and those days are becoming more and more frequently. This week had one of those days.
In school, we are taught how to double check to make sure we don't make medication errors. But despite those checks errors still happen. The other day *I* made a *serious* medication error, and it could've gone very badly for the patient if I hadn't caught it.
See, the patient I had was critically ill. I'll call the patient Tar Baby (TB). Tar Baby's heart was NOT doing so hot, but this medication was one no one can take home. It is *that* strong. But every time the doctor tried to wean Tar Baby off, TB would bottom out. (TB's blood pressure would drop dangerously low). When I was there we were doing the same thing again. TB had two heart medications running through its IV, one I'll call Snickers and the other Baby Ruth. The Baby Ruth med we *had* to wean TB off of. If we couldn't get it off, TB just wasn't going to leave the hospital alive. The Snickers med was the one the doctor said TB could come off of, so I disconnected the Snickers IV line, set the Baby Ruth IV pump at a slower rate, and waited. Just like before, TB's blood pressure started to drop.
Something felt wrong to me however. No matter how high the nurse was setting the pump, the patient was still dropping. That was just not possible. There were about...seven or eight meds running through IV lines simultaneously, and I was stricken with a sudden fear that I had possibly disconnected the wrong IV line, even thought I *knew* I didn't. My gut told me to check, so that's what I did. I had a shit-fest when I found what happened.
For some reason, the Snickers med and the Baby Ruth med were hooked up to the same IV line. The Baby Ruth was what we called 'Piggy-back.' It was piggy-backed (hooked up to the IV line through a side port connection, called the Y-site or Y-port) to the Snickers IV line, so that when I disconnected Snickers, *both* medications were cut off, instead of just one. For the Baby Ruth med, you can't stop it suddenly, or else the patient will bottom out. And since we don't need to change IV lines except every 3 days...it became clear why TB kept bottoming out.
I fixed the problem immediately, and reported it to the nurse. Then it became clear why they were having so many problems getting TB off Baby Ruth. Since it was connected to Snickers, when TB's blood pressure got too low they would hook Snickers and Baby Ruth back up so that TB wouldn't die. It was going in a circle.
When my shift was over, we were preparing to discharge the patient home. The patient had weaned off Baby Ruth without any problems, and was stable. I was just upset about the whole thing, because if someone else made the mistake, it was on them. But *I* did it, and although technically the nurse said it wasn't my fault, I was still upset it happened.
Well, that's my spiel. I'm hungry. Good night everyone.