“You’re not a good healthcare provider until you’ve made a medical mistake. You’re not a great one until you’ve killed someone”
That’s what they told us in nursing school. That’s what they repeated in nurse practitioner school. The ER doctor I spent months working with during clinical rounds even had a chart graphing out what happens before, during, after and then down the road when it happens. It always happens.
In most other professions, when someone makes a mistake it can be expensive, frustrating, career ending even, but is it not often fatal. Yes there are high-risk professions like mining and roughnecking where mistakes can be catastrophic but that isn’t the same as a person coming in to be saved but being killed instead. If I make a mistake caring for an emergent patient, there won’t be time to fix it. A person in a true emergency is actively on the brink of death. We have to get it just right to even have a chance at saving them.
I spent almost five years working in the ER. My patients often came in the sickest but my positive outcomes far exceeded standards of care and my door to floor (for ICU patients), door to cath lab (for someone having a heart attack), and my patient satisfaction scores, by every measure really, were at the top in the department.
Except for that one night.
It was a long, long time ago, one of my first nights working in the ER, fresh out of nursing school and before I even started on my nurse practitioner program. I was new to everything, still trying to find supplies and get the electronic charting down in addition to taking care of my patients. The other nurses were good about helping me when things got crazy but it was night shift, a skeleton crew, so there were only a few of us on the floor to begin with. I found it hard to be a thinker in those early days with so much task management piled on top of me in a busy, short-staffed department and I relied heavily on “just getting it done” which turned out to be a lethal coping mechanism that night. The night my patient died by my hands.
He was the victim of a random mugging. Some guy had jumped him out of nowhere, hit him in the back of the head with a heavy object and stabbed him in the back before making off with his wallet. Someone brought him in by car, dumped him off at the door before taking off leaving him to present at the triage window bleeding and screaming.
The triage nurse brought him back to my trauma room, trying to get an understanding of what happened. He was speaking English at the main door, switched to his native language half way down the hall and was only uttering gibberish by the time he got to the room. It was going south really fast and we knew he was in bad shape.
We had called a trauma alert even before he hit the room so we did what we always do very well and quickly: c-collar on his neck, IV inserted by the tech, on the monitor by a nurse and clothes cut off to see how/where he was injured, etc. We saw the giant stab wound on his right flank and the night doc called for a catheter to check for blood in the urine. We had the catheter inserted in a flash and my fellow night nurse yelled, “positive for blood!” which meant the stab wound went all the way into the kidney. We were in the middle of the rest of the trauma protocols when he started projectile vomiting.
“Drop a NG tube,” the doctor barked at me before walking out to the desk to make sure cat scan was ready for us. (NG is short for a tube that goes up the nose and back down into the stomach to prevent any stomach contents from backing up into the lungs) With the rapid deterioration and head injury we needed to see how bad things were via cat scan imaging. With his vomiting we had to protect his airway while he was lying flat on his back on the cat scan table and decompress any stomach contents prior to surgery so it was the natural call but something wasn’t right. I stopped for a second and paused. “But, wait,” I said to the room, trying to think through all the noise and tasks and stress to get to that something flickering in the back of my brain trying to tell me not to drop the NG tube. Wasn’t there something about…
“DROP THE DAMN TUBE!” screamed into my ear making my whole body jump as the doctor re entered the room. The tech had already prepped the tube, connected it to suction and was handing it to me to insert. I had it in my right hand and stopped again, begging, in my mind, for just a second, one second to think about head injuries and NG tubes and…
“NOW, GODDAMNIT!” the doctor screamed again so I introduced the tube into my patient’s nose. I didn’t know his name. We never knew his name. All of his paperwork was “John Doe” but with the Eastern European language he was speaking in the hallway before going downhill, his name probably wasn’t John. This man I didn’t know who was actively dying, someone’s son, friend, maybe even father who showed up terrified and begging for help before being placed in my trauma room was lying in front of me. My patient. My responsibility.
The tube started up his nose. There is a sweet spot where, if you give the tube a little twist, it helps round the corner and progress down the back of the throat to the stomach. I got to the depth where the tube was ready to make the turn. I gave just a little twist and advanced and…
The tube didn’t turn.
It didn’t meet any resistance.
That fat, stiff NG tube designed to withstand the acidic environment of the stomach…
Proceeded, uninhibited, right into his brain.
I could feel the soft folds of his brain at the far end of the tube give way and turn to mush. “Oh my God!” I screamed inside my head. My heart stopped, my breathing stopped, my jaw dropped and everything went odd and terrifying, like after an explosion, and I knew. I knew what I had done. And then I remembered what it was my mind was trying to tell me: you can’t drop a NG tube on a patient who has a posterior head injury because the force of such an injury can cause the bones in the back of the nose to break. I had just lobotomized my patient.
I withdrew the tube gently but it didn’t matter. His pupils instantly reduced to pinpoints in eyes that fixed hard over to the right as he started seizing. It was over, he was over and nothing we did next could possibly fix my mistake. The rest of his time in our hospital went by the book: the NG tube dropped from his mouth instead of from his nose into his stomach, cat scan completed and on the helicopter to the neurosurgery center hospital all within twenty minutes of his showing up at our front door. He made it to the neurosurgery hospital but not alive. His heart stopped beating in the helicopter en route. They worked on him for a long time both in the helicopter and upon landing but there was no saving him.
And there wasn’t going to be. His head injury was fatal. One look at the cat scan images of shattered pieces of bone splintered throughout the back of his massively hemorrhaging brain and we were all shocked that he was even conscious after taking such a hit, let alone able to speak for those first few minutes. We found out later that the attack occurred just blocks from the hospital. Any farther away and he would have died way before any attempt could have been made to save his life.
I killed a man. It happens in healthcare. It always happens. Medical mistakes are often fatal. Sometimes it is a system failure that leads to the mistake, sometimes it is a prescription error that leads to a fatal combination or concentration that causes death but, in my case, the death was caused by my own hands, by my right hand.
I remember him every day. I remember his dark, curly hair and his pale green eyes that were the color of a Caribbean lagoon. I remember the heavy collection of freckles that ran across the tops of his shoulders before giving way to clear, olive skin, broken by the angry puncture of a knife wound. I remember he was young and strong and had a beautiful face marred by the classic scars of a fighter’s life. And I remember exactly what it felt like to accidentally take that life when I shoved a tube deep into his brain.
After that night, things were different. I was different. I’ve never again silenced the voice inside of me. If I’m not sure, I don’t proceed, and every time it matters. Every time it makes a difference and I’ve been better than I should be throughout the years. It wasn’t the doctor’s fault I didn’t listen to it that fateful night, it was my fault I didn’t listen. It was a lesson I needed to learn, that most of us in healthcare are destined to learn.
I’ve often thanked God for giving me the gift of learning that lesson on a dying man. A man who had no business being alive in my trauma room with the extent of his injuries. A man who made me a much better nurse practitioner, even though the memory of him is a hard one to carry. Great gifts are often difficult and always come with great responsibility. I hope I can live up to this one.