Critical Cover-Up

Chapter 3

Chapter 3

Two months had gone by since Joe’s death, and his murder remained unsolved. Allison had taken two weeks of personal leave, and although an emptiness still existed, she knew she needed to be productive. She was grateful to immerse herself in the hospital work that she loved.

The constant shrill ringing of the red alarm on the cardiac monitor almost made Allison jump out of her seat. As she rushed to Room 4 at the end of the unit, she heard the overhead announcement, “Code Blue Surgical Intensive.” Her adrenaline spiked in anticipation of the crisis, and her heart pounded in her chest. Thank God it’s not my patient. When she reached the room, she saw an elderly patient, his face a cyanotic shade of blue. He appeared unresponsive.

Dave Kellen, the competent and calm night shift charge nurse, began providing artificial respirations with additional oxygen, while two coworkers, Melanie and Karen, worked with efficiency to attach the defibrillator pads and place the backboard between the patient and the mattress to provide a firm surface for performing CPR. Glancing at the patient monitor, Allison could see that his heart rate had slowed to thirty-six, and the blood pressure cuff was not registering.

“He has no pulse. Start compressions. Allison, you’re the recorder,” Dave directed as the code leader. Once the code board was in place, Melanie began chest compressions. Allison picked up the code sheet which was hanging from the crash cart and immediately began to document the events.

Respiratory therapy and the ER physician arrived in less than a minute. While pushing an amp of atropine through the patient’s IV line, Karen updated the ER doctor.

“He’s a post-op thoracotomy patient from two days ago and had been stable on a Venti-mask. I heard the alarm, and when I came into his room, his mask was off, his face was blue, and he wasn’t responding. I think he had a respiratory arrest and then brady’d down,” she explained, referring to the slow heart rate.

As the respiratory therapist prepared to intubate the patient, the ER doctor asked, “Does he have a pulse?”

Stopping compressions for a few seconds, Melanie felt the patient’s groin for a pulse. “I don’t feel a pulse.”

“Continue compressions and give an amp of epi.” The crash cart was open, and Karen already had the epinephrine ready to inject, as she knew the protocols backward and forward. All the nurses in ICU had to maintain proficiency in Advanced Cardiac Life Support and had numerous opportunities to hone their skills and gain valuable hands-on experience in code situations like this. ACLS was one competency in which everyone made sure they knew what to do, since these were truly life and death situations.

To a bystander, the nonstop scene might have seemed chaotic, but everybody had a task to perform and things worked well. In addition to those already in the room, a lab tech showed up, as well as an EKG tech and a nursing supervisor. Within a minute or two after the start of the code, the patient had been intubated and another respiratory therapist was ready with the ventilator, so the patient could be mechanically ventilated for now.

Dave asked, “Did anyone contact the family?” A secretary indicated that she would get the family on the phone.

After the epinephrine had time to circulate and the patient was ventilated, his pulse returned and he had a blood pressure that was adequate. His color was no longer blue and his skin was warm and dry, so the Code Blue ended.

“Good job, everyone,” Dave said. All involved felt good that a life had been saved.

“Are you ready for the x-ray?” asked the radiology tech, pushing his machine into the room to shoot the chest film which would verify proper placement of the endotracheal tube.

“Do you need anything else from me?” the ER doc inquired.

“Just your signature on the code sheet, please, and we’ll need the order for Diprivan so we can maintain sedation while he’s on the vent,” said Dave.

Karen reached the family by phone, explained what had happened, and then contacted the patient’s doctors to update them. The rest of the nurses left the room to attend to their own patient assignments.

Handing the code sheet to Dave, Allison said, “I know you need to double check everything here. Please let me know if I missed anything before you turn it in. Thanks, Dave.” She smiled, invigorated, with a renewed sense of purpose. “We got him back pretty quickly.”

“Yeah, that was good. He looked pretty bad. I wasn’t sure if we were going to be able to resuscitate him,” Melanie said.

I love being a nurse, Allison thought, still experiencing the adrenaline rush. Events like this contributed to a sense of camaraderie among the staff. Her occasional frustrations over the incessant documentation and hours of duplicate charting melted into the background.

Allison had participated in just a few codes before now, so she lacked confidence to assume the role as leader, but she liked the involvement and learning. She felt comfortable doing the transcribing, and in past codes she had performed cardiac compressions as well as ventilated the patient with the Ambu bag attached to oxygen. She had not run a code nor had she ever been the one giving the IV medications, so she knew that she needed more experience before she could feel at ease with these ICU emergencies.

After Allison’s shift ended at 7:15 a.m., she drove home, still wired from the events of the night. In her mind she reviewed the code several times. Her OCD tendencies forced her into this ritual after any serious situation at work, and sometimes she couldn’t stop obsessing about it. She had difficulty falling asleep some mornings because she was so hyper from everything that had happened on her shift. After a hot shower, she checked her email and flopped into her bed at nine o’clock. Exhausted, she fell asleep almost as soon as she closed her eyes.

***

Jolted awake by the ringing of her cell phone, Allison answered in a deep, groggy voice. The familiar enthusiastic greeting of Jamie, her longtime real estate friend, brought Allison to life.

“Hey, girlfriend! Long time no see. What’s going on?”

“Jamie, it’s so good to hear your voice. What time is it? I’m just waking up, and it’s been a busy week—last night, especially. One of the patients coded and I got to participate.”

“Sounds exciting but also exhausting. I don’t know how you nurses do it. It takes a lot of energy to save lives every day. I give you a lot of credit, Allison. Do you ever regret leaving the real estate office?”

“No. I love making a difference in my patients’ lives. Closing a sale on a house can’t compare to last night, no matter how much more money I might’ve earned.”

“It’s three o’clock. I hope you had enough sleep. Are you up for some karaoke tonight?”

Allison welcomed a chance to get out instead of staying in to study. She spent long hours on her days off reading critical care books, as well as journal articles from the American Association of Critical Care Nurses (AACN) website. She knew there was so much more to learn, so she tried to educate herself on the latest protocols from the American Heart Association and read medical news from Medscape. She realized the need to be a little more balanced, so Jamie’s phone call came at a good time. “Okay, count me in. I do need some time away from all this seriousness. But no singing for me. I’ll be ready by nine.”

After a few days off and a night out with her good friend Allison was ready to get back to work. As she walked into the hospital, she smiled to herself and felt full of energy. I wonder what new and exciting things lay in store for me tonight. Looking at the assignment board, she was pleased that one of her patients was Mr. Wetherly, the gentleman who had coded a few nights ago. She wondered how he was progressing and asked Connie for an update. Disappointment soon superseded curiosity, as Allison learned the man’s condition had deteriorated. He was still on a ventilator, and three additional consultants were now managing his care.

“He’s battling pneumonia and is in septic shock. He’s requiring high doses of Levophed.” Allison knew it was one of the strongest intravenous drip medications for controlling blood pressure in such situations. “Despite the fact that he’s receiving several antibiotics, his prognosis isn’t good,” Connie said. “He hasn’t regained consciousness, even with no sedation. I discontinued the Diprivan for blood pressure reasons and due to his neurological status.”

“Has the family been advised about the gravity of the situation?” Allison asked.

“Yes. They live up north and are on their way down. We told them he might not live through the night. They made it clear that they want us to do whatever we can to save him, so he’s a full code.”

“At eighty-four and in his condition? I know I would just want to die in peace and not be hooked up to all this stuff. I don’t think families have any idea what these patients go through sometimes.”

“Tell me about it. They aren’t here to see what we have to put these poor patients through. And even with a living will, it’s not too cut-and-dried. Maybe when they arrive and see for themselves how it really is, they’ll reevaluate their decision.”

“I hope so.”

Allison’s other patient was a stable post-op gastrectomy who was still on the ventilator. We’ve been getting a lot of these stomach removals lately. I wonder if it was due to cancer. She knew she would be busy but could handle the case, which was a typical ICU assignment. She went to look for the other nurse who would give her report, grateful that it was a traveling nurse and not Connie Gaston, who was almost never ready. She was able to take a quick report and could start her assessments in a timely manner.

The unit was full, so it looked like her shift would be busy. They were also one nurse short, since someone had called in sick and not been replaced. Word from top management was the usual explanation: “There aren’t any nurses available.” One nurse now had three patients, and the charge nurse had one patient and an empty admission bed. This was becoming the status quo lately, and Allison did not recall the staffing being so tight when she worked her clinical during nursing school. Good thing she enjoyed the work so much that she didn’t mind being busy. It was the frickin’ paperwork she detested.

***

By 2:00 a.m. Allison had gotten caught up with her work. Thank God Mr. Wetherly is somewhat stable. Allison doubted that anyone outside the medical field would describe a critically ill patient in those words. It seemed like an oxymoron. His blood pressure and heart rate were maintaining within the parameters ordered by the physician, although he required high doses of vasoactive medications to achieve those numbers. As Allison reviewed the electronic chart and checked his orders, she became curious as to the events which led to his respiratory arrest a couple of nights before.

Unable to find any new information from the physicians’ progress notes, she approached the central station monitors. I know there’s a reason he coded, and maybe I can find something here, she thought. Zeroing in on Mr. Wetherly’s information, she backtracked to the day in question.

She located his patient data screen and studied his vital sign trends. Her inquisitiveness became an obsession for a few minutes as she zoomed in to the time of the code. She sensed she was on the verge of uncovering something.

“What is this? Oh no. Do I really want to see this?” she said. What had triggered the alarm was not only a heart rate of forty-five, but an oxygen saturation of fifty, which was quite low. After more investigating, Allison discovered that the oxygen saturation had been low for an hour before he coded. The last time it had been within normal limits was an hour and five minutes prior to the code, and at that time it was reading ninety-five percent. The number consistently decreased from there until it reached fifty. She knew this was not good. The alarms for O2 sats were always set for ninety-two or ninety-three, since anything below that was abnormal. Why didn’t someone check on this patient when the alarms went off? she wondered as a heated flush spread up her chest and across her face.

Allison then checked the alarm review for the same time period and found close to 100 instances when the alarm had been triggered for low oxygen saturation.

Her stomach roiled, and she swallowed back the wave of nausea that followed. Why didn’t someone see this? She printed out the alarm events and also the patient’s vital signs from that terrible day and shoved the papers into her bag. Glancing around, she noticed that she was the only one at the desk and felt relieved that she was not being watched. Maybe she would reevaluate the information later when she had more time. Her gut informed her that something wasn’t right, and she knew this information was something she had to save.

The more she contemplated what she’d discovered, the more anxious Allison became. She knew that sometimes nurses just silenced the alarms when they were sitting at the desk and didn’t really investigate the reason for them. Most of the time it was insignificant and an annoyance, such as an irregular heartbeat in a patient everyone already knew suffered from the problem. But this was serious, and Allison thought she recalled a nurse sitting near the monitors for most of the night before Mr. Wetherly coded. She remembered that the nurse was Paula, an experienced ICU nurse who had worked in that unit for at least three years. Now Allison recalled that Paula had been sitting near the monitors that night and silencing alarms while she was charting. Had she silenced Mr. Wetherly’s alarms? Possibly. Probably. But Allison had not witnessed it. She could identify the nurse, but she couldn’t say for sure that this nurse had turned off any alarms, since she wasn’t specifically observing her behavior. But someone had to have silenced those alarms.

The sense of unease didn’t dissipate, and Allison wasn’t sure what she should do. If I don’t say anything, nobody will know and nothing will happen to my coworker. Allison had this gut feeling that if the alarms had not been silenced, Mr. Wetherly would never have had low oxygen saturation for a long enough time to cause him to stop breathing.

***

For the next two days, her stomach was killing her as she couldn’t stop thinking about Mr. Wetherly’s situation. Is it my responsibility to say something? Will it make any difference?

When she came back to work that night, she found out that Mr. Wetherly had died during the previous shift. The nurses had coded him with the family present, but the sepsis was too advanced and he didn’t survive. She tried to tell herself it was for the best, that he would never have been the same, but she knew better. Mr. Wetherly never should have arrested in the first place.