From the book – Wall of Silence
From the book – Wall of Silence “It’s hard to kill a 15 year old” History: Lewis was born with pectus excuvatum (Hollowed chest). A mild case of abnormal growth of the sternum and the adjoining sections of ribs. As an avid soccer player and engaged ninth grader, Lewis and his family decided to undergo a new, minimally invasive surgery that was supposed to be safer and quicker than the older method of opening the chest and remodeling the ribs and cartilage. It was recommended to perform the surgery now as the procedure would be more difficult as Lewis got older. Surgery: The surgery was to take 45 minutes – Lewis’s took 2 ½ hours. Recovery: Lewis was producing abnormally low amounts of urine. Was given Toradol – a nonsteroidal anti-inflammatory drug (this drug has a warning for administration during low fluid output and for children) Day 3: Pain increase, Vital signs began to deteriorate: Mom’s journal: Lewis’s bowel and urinary system are still not functioning. His belly is hard, he is pale and in constant cold sweats. His eyes are sunken. He is in pain radiating to his shoulder and is nauseated. We have called the nurse a number of times, she seems convinced that Lewis is lazy and not walking enough to dissipate his gas pains. The ward is busy preparing for a Joint Commission visit the next day. I call and sometimes no answers or the receptionist answers exasperated. I hear the nurses laughing and decorating for the visit. Our request for a senior physician in the face of Lewis’s increased pain and weakness are resisted from the nurses. However, someone finally calls a Dr. A fourth-year general surgery resident arrived, first time to visit Lewis. He agrees with the nurses that it is gas pains. Lewis had not urinated in 12 hours, they do a straight cath and find 215cc. The Dr. orders blood test – Not a blood count that may have shown infection. The next am they could not get a blood pressure – they tried 12 different times, with 7 different cuffs. At noon Lewis arrested. They told us they did not know why he died. It became the family’s mission to find out why their son at the age of 15 died. The autopsy identified an undiagnosed perforated giant duodenal ulcer. Lewis had developed peritonitis, and had lost more than half his blood into his peritoneal cavity. Questions: A Root Cause Analysis would be performed- Why? What is the name of this type of an event? What organization requires that a RCA is completed due to this type of event? If you were part of the RCA – what method of RCA would you use and why? Pick a second RCA method and describe the methods process and why this may be beneficial in this case. The system failed Lewis and his family, as a student nurse, what lessons learned do you see and how will this shape your career? Visit the Agency for healthcare Research and Quality – visit Patient and Clinician Videos. Select one, view, write what one you viewed and your reflection about the video – what did you take away. https://www.ahrq.gov/patients-consumers/patient-involvement/ask-your-doctor/videos/index.html Visit the Quality Safety Education in Nursing at https://qsen.org/quality-and-safety/ Tab down to the section: Quality & Safety Issues in Primary Care Practice. Pick one and comment on the importance of this area for education.
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