I thought of Linda L. as the Unit’s Oracle back then, my own and portable Delphi. With the distance of time, my memory of her has changed, and when I look back I now see her as more of an early beta version of Google. She was full of helpful hints, cautionary warnings, and she was easy to access.
She was also the cause of the biggest mistake I was ever involved in as a nurse.
I was in love with Linda L., but it was a strange love. I was confused about women and tried to deal with this confusion by dividing the women I met into two categories. Based on appearance and attitude, they were either a Madonna or a Whore. From this organizational trick of mind, I based moves and plotted strategies. It was limiting. (It was later in my life that I figured out that the good ones were both at the same time.)
I was confused, not so much about the Madonna/Whore thing, (because that seemed pretty straight forward,) but from all the crazy types of women I kept running into that didn’t fit into my prepared either/or boxing system – the Old Bat, the Cat Lady, the Lesbian and the Blond, all of these variations on the theme of Woman. The possibilities for classification began to seem endless to me. My systems of belief were falling apart on me.
Using my limited system, Linda L. fell on the Madonna side of the pedestal, but on the Madonna side with an asterisk.
She was also a witch -- a real Wicca kind of witch.
Since I am one of the few non-Jewish white people alive today who thinks the New testament was just an unnecessary gilding of the lily, Linda and I probably should have hit it off even better than we did. The witch thing was interesting, but I was having my own problems with a punishing all knowing god. We never talked religion.
Dark eyed and Italian, she walked with her feet slightly splayed, and carried an extra 20 pounds of weight on her. She carried it as if it were a 100 pounds. I think she carried a lot of invisible stuff most of the time.
My memories of her include: the sight of her at the end of a hall walking away from everything while pulling up her panty hose, uniform and all, using her two hands to work them back and forth until the panties were again above her hips.
I loved her extra weight. I hated that she hated it. When I learned that later in her life she had become a food Nazi, (No sugar! No wheat!) I almost cried, but I wasn’t surprised.
She liked to be around me, though whether it was to fix me or touch my magic I was never sure.
She was the smartest unsure person I have ever met. She knew everything, but when she told you things, it was as if she were asking you a question.
In the unit, I thought of her as the perfect nurse. She was neat, clean, and always a help to everyone around her. She left her patients in as good a shape as they could be left in, and when she told you a thing it report, you didn’t need to check on it when you went into the room to make sure it was true.
Because, everything she did required that she triple check herself to make sure. This made a mockery of most other forms of anal retentiveness, at least as lesser women practiced them.
Most of the worthy kinds of fanatical attention to detail don’t come out of the pathology of abuse or revenge, but rather, they come naturally from the obsessive cultivation of a personality that trends that way in the first place.
I have found that I admire people who come out of the womb full-blown bat shit crazy and, over time, learn to accept the structure that it provides, and then pass it on to others in fun new ways. They become what they are.
Then there are the pathological people who become crazy after getting abused by others when they are young and unable to defend themselves. I feel pity for them, but don’t like to be around them much. Abused people pass it on, but it’s not as much fun. They become what they were made to be.
Linda L. was born slightly off, much to my delight.
Our relationship was based on work. We didn’t lunch, together, see movies or plan trips to Europe. When we worked the same shift, at some point during the day, Linda L. would end up standing next me, looking over my shoulder, making comments about my work. The comments were usually short and clipped – informational content slipped into me without lubrication.
Then she would turn and waddle away, a chubby girl trapped in a fat girls head.
In some ways, this might have seemed just a shallow and casual flirtation between two strange people – but what Linda lacked in the conversational, she made up for in persistence. We spent a lot of short intense time together. She wasn’t a talker, but I wasn’t a listener, so it worked.
When Linda L. talked, her words were only the tips of an iceberg. If she said something to you, it required deep thought, and usually some form of research to see it in all its glory. In all the various ways that a person can learn something from another person, her way was the one that made me sit up and pay attention. She was a teacher to the part of me that felt abused by teachers.
Still, my biggest mistake as a nurse came when I followed Linda L. and forgot to check her work.
(Hospitals deaths due to mistakes total over 100,000 a year. This simple statement should be read over and over—100,000 deaths each year because of mistakes made in hospitals. 100,000.)
Cardiac surgery patients lose potassium. Without potassium, the heart becomes irritable, and this irritability causes arrhythmias to happen. Arrhythmias led to death.
On the cellular level, heart contraction occurs as sodium and potassium exchange places. Trauma to the heart – surgery, heart attack, stabbings all force potassium to free up and leave the cells, to then join the blood supply and eventually to get eliminated as urine. Without potassium available to exchange with the sodium at the cellular level, the heart seizes up and refuses to contract – it gets stiff and non-compliant -- it slows down and stops working.
After cardiac surgery, potassium levels would get checked on patients every four hours for the first few days. Using a formula, nurses would replace the lost potassium in the patient, based on the reported lab levels. The nurse added a measured amount of potassium chloride to a small amount of an IV solution, and then mixed it into a separate bag. The bag was then hung to an IV controller and the rate of flow set by manipulating knobs. The potassium was then run into the patient over a set amount of time – usually an hour or so.
I was assigned a post-op open-heart patient when working a night shift. The nurse I relieved was Linda L. and I was happy. After a quick report, I said good night to her and went into the room to evaluate my patient. A little old lady was lying on a neat bed, with crisp hospital corners on the sheets, and every line going into her labeled with tape that clearly identified what it was in tiny, perfect lettering. As I looked around the room I thought, “I can only screw this up.” I sat down, away from the patient, and started reviewing the chart.
About an hour into my shift, I noticed that my patient’s heart rate was slowing down significantly. As I looked around the room, trying to figure out why this was happening, I got distracted by a small staff of wheat that appeared to have been tied together in a bundle with a human hair. It was stuffed into a fold in my patient’s sheet. Knowing that it was just a little something of a message, or statement, from my Wicca friend, Linda L., I looked for more.
I found a small crystal hanging from fishing line taped to the window, a paper drawing of a goat with small misshaped horns, and a chalked geometric maze on the back of the clipboard I was using to hold my notes together.
At that exact moment, the maze moment; I saw that the IV controller was set to deliver 666 drops of potassium every minute, instead of the reported 60 drops; I heard the monitor alarm bonging; I saw that my patient’s heart rate was now 30; and I saw that she had no blood pressure.
I thought, “That’s the mark of the beast,” and, “That’s not very Wicca of her.”
I acted. I reached over the bed and yanked out the potassium line. I grabbed a big syringe and started sucking out blood from the site the potassium was infusing into. I opened another IV and started pumping fluid into her. Help came from outside the room: The code cart was wheeled in, additional IV’s were started, and sound and fury was unleashed across the unit.
After an intense hour, the patient stabilized, and the time of paper began. I filled out an incident report and finished the night without further drama. The little old lady survived and went home a few days later.
When the Director of Nurses confronted Linda L. the next day, she denied having set the controller to 666, and said that I must have changed it at some point during my shift. A few days later, procedures were put in place to keep this kind of mistake from happening again: The pharmacy started pre-mixing the potassium for us and a sign off sheet was added to our verbal reports.
I was written up for not checking my patient appropriately. Linda got worse; she had to keep living with herself, and I moved her to the Whore category.
Everyone lies and everyone makes mistakes. I learned.
Honesty and the willingness to admit to mistakes are not really all that important on the individual level. A good manager should be able to supervise the stupid, educate the ignorant and isolate the liar. It’s only on a systems level that honesty becomes important.
When people honestly report their mistakes, the cumulative weight of numbers add up when trying to figure out the big picture of mistakes -- and in these numbers the solutions can be found.
If a spike is noted in number of potassium mistakes, labels can be checked and procedures for its use can be evaluated. Maybe the buyer for the hospital bought the bottles on the cheap, maybe a simple change in how they are labeled can fix the problem.
Because most mistakes are not isolated – they are the end result of a series of mistakes. Here’s an example:
A person whose job depends on him saving money purchases potassium for the hospital. He sees a special buy on from a supplier, so buys a large shipment.
The supplier has the special buy because he changed the bottles that it came in to lower his costs. The potassium bottles are now the same size as the bottles that heparin comes in. To save even more money, the supplier also changed the printing on the bottles – he took out the color, so now they are black and white.
A smart buyer with a large standing purchase order for the potassium noted the changes and canceled his order, because, who needs the grief? Now the supplier has a large amount of potassium just taking up space in his warehouse, so, he decides to dump it at a low cost.
When the new supply arrives at the hospital, the Pharmacy discovers that the new bottles no longer fit on the shelf that they usually do, so they move them to another area that consists of a large bin. Since all of the bottles look pretty much the same, and because the pharmacy just has the one bin, they throw all of the bottles into it – even though the dosages for each bottle are different. Since they have never had a problem with potassium before, they can’t imagine having one now.
Because of sick calls, only one pharmacy technician is on duty filling prescriptions for the entire hospital. Since he’s got a lot of experience, and could find things with a blindfold on, he rushes as he fills his orders. He notices that the potassium looks different, but throws a handful into a cardiac patients bin without thinking about it too much. He knows that the nurse will double-check the order for him when it gets there.
The potassium arrives in a plastic bag with the dosage and patients name on it. Since the nurse has never had a problem with the pharmacy getting things wrong; since she is very busy with a critical patient starting to go south on her; since the lighting is poor in the med room – she draws up the medicine and overdoses her patient.
This is a system problem. Solving it requires that the end of the chain – the nurse – acknowledges the problem. If she doesn’t bring it up, none of the seemingly small actions that happened as the chain unfolded will get addressed or corrected – without the damage of the end, no one will have the right perspective to see the parts that make the whole of the problem -- Not the business owner making a borderline decision to save money, not the buyer trying to save his job, not the Pharmacy not seeing the need to change its shelving system, and not the overworked technician trying to cram a three person job into one.
Random, individual mistakes always happened. A distracted nurse can click a knob the wrong way and a medicine can end up in the wrong patient through sloppiness. To prevent these things from happening requires the diligence of nurses checking nurses, but they don’t happen that often, and are really not the bigger problem.
It’s system mistakes that were the real killers back then, and they probably still are.
Linda L. still came by to give me cryptic warnings after this incident, but not as often and she never stayed. She never acknowledged her mistake to me, much to my pity.