The Patient Was…

The patient was a 69-year-old man who was admitted to the hospital with a heart attack (myocardial infarction, in medical terminology).

A blood clot blocked the flow of blood in one of his coronary arteries, preventing oxygen-containing blood from reaching the heart muscle. Without sufficient oxygen, a portion of the heart muscle was dying.

Patients in the acute phase of a myocardial infarction are often medically unstable and require careful monitoring and close attention. This recognition led to the development of coronary care units in the early 1960s, but when these specialized intensive care units for cardiac patients were first introduced most hospitals did not have them.

I was an intern at the time this patient was admitted to the hospital, and I was assigned to his case. Our hospital did not yet have a coronary care unit and, to make matters worse, the medical wards were full so the patient was placed in a single room in a part of the hospital far from the physicians who would normally care for patients with heart attacks.

The patient did not have a personal physician, so his care was directed and supervised by a resident physician and me. The resident spent most of his time on the medical wards, so I was going back and forth between there and the patient’s room in another part of the hospital.

The nurse staffing at night was limited on the floor where the patient was located, and I was concerned that a patient with a heart attack could deteriorate suddenly and the nurses on that floor might not be aware and available to react quickly enough.

I asked the hospital administration to provide a private nurse for the patient and they obliged. Now, the good news about a private nurse was that there was someone with the patient all the time. The bad news was that the busy staff nurses essentially ignored a patient with a private nurse.

I had previously neither met nor worked with the private nurse who had been assigned to the care of the patient, so I had no idea of her training, experience, and ability. When I explained his condition, an acute heart attack, she seemed to grasp the problem. I remarked on the potential medical instability of such patients, and the need to carefully monitor vital signs such as blood pressure, heart rate, and breathing rate. She nodded her understanding.

Before going to the on-call room where interns on duty slept  —  when conditions allowed it  —  I made a final visit to the patient in his room far from the medical wards. His private nurse was there, and everything seemed stable. I wrote an order in the medical order book for the patient’s vital signs to be recorded every half hour through the night. The nurse saw the order and acknowledged it.

Unusually for a night on-call, I actually got a few hours of sleep, undisturbed by any calls for my assistance or presence. I had set my alarm for earlier than usual so I could visit the heart attack patient on the remote floor before reporting to the medical wards. When I arrived at his room, he was lying flat in bed, already cold and obviously dead, and well beyond any resuscitation attempts. 

I looked at the nurse incredulously. “What happened,” I said.

“Nothing.” She replied, “I did as you ordered.”

“What do you mean?” I practically yelled.

“Here,” she said, thrusting her nurse’s notes at me. “I recorded his vital signs every half hour, as you said.”

I looked at the papers and, sure enough, every half hour there was a notation of his blood pressure, heart rate, and breathing rate. Starting about 2 AM, his blood pressure had begun to fall, and his heart and breathing rates slowed. Over the next couple of hours, the nurse dutifully recorded the falling blood pressure and decreasing heart rate and breathing rates. About an hour before I arrived, the nurse’s note read, unbelievably: Blood pressure 0/0, heart rate 0, respiratory rate 0.

I called my resident physician, then turned to the nurse. I could barely contain myself, but tried to maintain some semblance of equanimity.

 “Why didn’t you call me?” I asked, trying to remain calm.

“You didn’t say to call you,” she replied, unperturbed.

“Why do you think I wanted his vital signs monitored?” I said.

“For the record, I guess,” she answered.

“Didn’t it occur to you to call me when you saw he was dying in front of you?” I said.

“Your order just said to record his vital signs,” the nurse said. “It didn’t say to call you.”

I stormed out and called my resident physician to explain what had happened. He was appalled, as I was. When he asked what I was going to do, I told him I was going to report the nurse to the hospital administration and get her fired. I recall being slightly surprised that he didn’t offer to accompany me. It didn’t occur to me at the time that maybe he had had more experience in situations like this and knew what might transpire.

The administrator listened sympathetically to my story. He seemed genuinely upset by what I recounted. It was a terrible thing, he said, and should never have happened. I was sure he agreed that the nurse should, at a minimum, be fired from the hospital roster.

I was wrong.

He said they would talk to the nurse, explain to her that what had occurred was a mistake in judgement on her part, and should never happen again. But he balked at firing her.

“She’s dangerous,” I said. “She let the patient die without calling for help. You have to fire her!”

As I persisted in my argument that the nurse should be fired, the administrator pushed back harder. He reiterated her argument that my order said to record the vital signs but did not specifically say to call me if things went bad. So, technically she had not done anything wrong.

Finally, came the denouement, as he issued what was essentially a warning to me: “It’s easier to find a new intern than a new nurse.”

It was clear that if somebody had to go, it was likely to be me. Nurses were apparently in shorter supply than young doctors. The only agreement I was able to reach was that that nurse would never again be assigned to one of my patients.

I never saw her again.