As hard as I try to never think about work at home, I often find myself daydreaming about things that have happened at work. If I'm lucky, I share my humorous stories with friends, we have a laugh, and we move on. If it's been a particularly difficult day, however, I often have trouble falling asleep or my dreams are filled with events from the day.

Today, for whatever reason, I couldn't stop thinking about one women I took care of over two months ago. I don't remember age, but she was probably in her early forties, and had fallen out of bed at home while her caregiver was asleep. Other than being mentally delayed she had never had significant health problems up to this point.

The previous night I had left work knowing that when I returned the following morning there would be a new admission in the room for me to care for. I arrived to work at 6:45am and started report with the oncoming nurse at 7:10am. As we're standing at the chart and checking medications, I'm listening to what happened to this poor women and it sounds like something that could happen in a third world country, not in North Carolina.

She had fallen out of bed at home five days earlier, been admitted to a small community hospital about an hour north, and upon admission she had a completely broken tibia and fibula. The night nurse giving me report said that upon arriving to the room at our hospital her vitals were elevated, she had an intractable temp of 103, and her left leg was at a ninety degree angle to her knee. Within minutes of her admission our Orthopoedic docs had placed and plastered her leg, and were rightly disgusted at the other hospital's negligence.

Peering into the room I saw a trainwreck. She was on a cardiac monitor, 4 liters of oxygen, continuous pulse oximetry, an IV drip, her heart rate was 130, her respirations were 45 per minute,and suction was set up at her bedside. Her most recent temperature at 0700 was 38.5 C axillary which translates to 39.5 and is lethal if not treated promptly. This poor women had acquired a raging infection from lack of care, and she was now fighing for her life. Her docs were aware of the situation, but all we could do was watch and wait. For the next three hours I spend mere seconds with my other patients, and was in this women's room the rest of the time. I had been administering rectal tylenol and motrin alternately as well as packing her with ice, but nothing would take.

I had notified my charge nurse of the situation, and we were both calling the docs to suggest moving her to the MICU. As I was preparing another Tylenol suppository her sister came out of the room and said " I don't think she's breathing as fast as she was, and this monitor is making a funny noise." At this point I'm thinking that this is good, her heartrate is in the 70's now, she's breathing at about 12 respirations per minute, and when I check her temp, it's 37.0 axillary. Just as I'm starting to have hope, I realize she's not breathing, and now her heartrate is in the 40's. Obviously things were not going well. I called a code blue, everybody rushed to the room, and immediately chest compressions were started.

After coding her for 45 minutes and finding a pulse for a few seconds we sent her to the CCU. When I walked down to the floor she was now on, her room was crowded and they were coding her a second time. She didn't make it.

Why did I choose to post such a long story? Why does it matter? It matters because I could never shake the feeling that this women's life could have been drastically different had the docs at her previous hospital stepped up and taken care of her leg. She should have been in the OR the same day she arrived to their hospital. She shouldn't have suffered, and she shouldn't have died, not like that. I was angry the rest of the day, couldn't focus, and even now as I'm typing this, all the memories come back. I decided that the only way I can have an impact from here on is to learn from the experience, and advocate more for my patients. If one med isn't working, let's try another, and quickly. If a patient is decompensating, let's send her to the MICU now, and not wait. Unfortunately I don't have much pull in those situations. All I can do is keep going down the chain of command until I get someone to listen to me, and more often than not that takes too long, and we've lost precious time.

With the bad comes the good, and I have had so many wonderful experiences since that day. There are always those patients that stay with you, and change your title from caregiver to advocate.