By: Debbie Moore-Black, RN

My first post-op night from my nephrectomy was short of fantastical to almost devastating.

I woke up in the PACU after my surgery. Extremely confused and disoriented. I felt like I was inside a video game and trying to frantically escape.

When I entered my new post op room on a medical surgical unit, it had that brand new hotel-like decor. A shiny and new unit.

The nurses and techs and NP’s greeted me. Great surgery, pathology reports will come soon of your nephrectomy, Renal Cell Carcinoma. You did well.

I always made sure to never work on a Medical-Surgical unt because the truth is, they are grossly understaffed. It’s a hard job.

Throughout the night, I heard an old woman chant repeatedly “help me , help me” over and over again, an older man obviously going through DT’s, falling out of bed and screaming incoherently.
It’s a hard unit.
I wanted to be the ideal patient!! Best behavior. No complications.

Night shift came, a vintaged nurse in her 50’s came to check in. She told me she was a traveler. Nurse patient ratio on this Med-Surg unit was typically 6 patients per nurse.
She appeared savvy, smart, practical.

She let me know she was a Sagittarius.

Interesting and strange because I would never be concerned about someone’s horoscope alignment. Especially a nurse. Odd.

0300 came. I started to have pain. Intense abdominal pain, at least an 8 on the pain scale of 1-10.
She gave me Dilaudid IVP.
Everything seemed well, the pain eased off,
But
Within 30 minutes I started to have shallow breathing. Forcing myself to breathe.
And I got scared.
I went into ICU nurse mode. Instructed my son (a highschool Math teacher) where the Code blue button was. If I deteriorated, I instructed him to call out “rapid response team stat”
Call my nurse, something is wrong with me. Shallow rapid breathing I thought I was going to code. The response time for this nurse was unusually slow.
I begged for a stat CBC as my hemoglobin was already under 9. The nurse refused. She said the lab will obtain my hgb at 5:00 am.
I need a nebulizer. I started to spout out orders that a typical ICU nurse would do.

She was lethargic, gave me an Ativan. Granted I was also having some type of psychotic reaction to the dilaudid but she was slow to move and obviously didn’t feel the impending doom that I did.
I apologized to her but said I needed help. I told her “I know too much”
Her response was “I know too much also. I’m a Sagittarius “

I made it through that night. I did not become a code blue or RRT, my NP came to make rounds on me, I told her my situation from last night. The NP said the only communication she had from this nurse was that I needed a Tylenol for a headache.
And by the way… my hemoglobin had dropped to 7.6.
She certainly put a big smear on this unit. This Medical -Surgical unit of nurses and techs working so hard. High acuities understaffed unit.

I’m thankful my son was with me. I gave him his first lesson in what it’s like to be an ICU nurse.
The importance of listening to the patient and the symptoms . The importance of being readily available to the patient and using critical thinking skills.

And the importance of never ever telling a patient your horoscope sign. A totally inappropriate response.

My first post op night: nightmare and incompetence. And reportable.

By Debbie Moore-Black, RN

(Warning: Sensitive topic)
** This is a composite story but based on facts. In 1997/1998 and in 2000. The difference in my story and the truth is several and many babies died from bacteria traced back to nurses fingernails as a contributing factor.

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That small cliquish bevy of nurses working their way through orientation in the NICU. Straight out of nursing school.
They were happy and thrilled to be accepted into this specialized nursing unit: the NICU.

Practicing good hygiene, washing your hands up to your elbows with soap each time you entered a babies cubicle, gowning and gloving was standard and mandatory protocol  before touching the babies.

These were preemies in the NICU.

Molly and her friends felt privileged and honored to get this job straight out of nursing school.

It was a fast paced NICU with levels 2-4. The higher the level, the higher the babies acuity. They were tiny and frail and had weak immune systems. Most were born prematurely. Others had defects, congenital anomalies and immature lungs. Some babies had to be fed by a feeding tube. Some were on the ventilator.             

This was the most sacred unit in the hospital because every nurse that came aboard knew they must always be meticulous in everything they did.

The basic cardinal rules though was to always wash your hands. And keep your fingernails trim.

The new nurses were fashionable. And pretty and smart. But they refused to let a protocol like having short nails bother them.
Management looked the other way when they saw the new grads parade in, with their glossy fingernails, long stiletto type nails.
I guess if they just looked away everything would be ok.

Baby Jessie  was a level 2 baby in the NICU. She was born prematurely, hypoglycemic, grossly underweight, and unable to feed without a feeding tube inserted through her nose that landed into her stomach.
She was frail but had big eyes and a hint of fine red hair. She was a beauty.

Her parents, washed their hands, gowned and gloved, held their new baby close to them. Every day they’d come for a visit. Hoping and praying for a progress report.
Each day seemed to be a new accomplishment.

Baby Jessie seemed to be progressing.

Though one day her status was changing.and changing rapidly.
Poor Jessie with her rapid respirations, diarrhea, a rash developed on her abdomen.
Fever developed, lethargy and Jessie was rapidly decelerating.
The sepsis protocol was initiated, stat labs drawn, ABG’s and an LP preformed.

A code blue was called. The code team rushed in. CPR, ventilator as baby Jessie went into asystole rapidly. Rounds of epi, bicarb and the code team couldn’t bring Jessie back.

After what seemed a lifetime, the NICU physicians pronounced her death, and sadly met her devastated parents.

An autopsy was preformed, bacteria was found. Ecoli. It was mandatory to report this to Infection Control and Epidemiology. The CDC was involved.
E. coli was found in Jessie’s bloodstream.

That new bevy of nurses. The fashionable ones, the ones with those long stiletto nails, the bacteria was traced back to their nails upon scraping and microscopic findings.

It was determined that two of these nurses
contributed to the death of this Neonatal premature NICU baby.

Beyond respecting and acknowledging the protocol on wearing short nails, of always washing your hands up to your elbows without fail each time a nurse entered a babies room in the NICU….. because of these nurses that failed to honor this mandatory protocol, a death was pronounced of this small innocent newborn baby.

Years of trying to finally get pregnant, yearning for that new baby, baby room decorated, crib with pink ruffles …..baby showers and happiness …..

Endless tears as baby Jessie lay lifeless in her parent’s arms.

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