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 Provided by Clinician 1
I’m sure most of us have had at least one patient that haunts us.
Something didn’t pan out the way we expected...either with a bad outcome, or a patient or family complaint. Or maybe it was an off-hand comment made during a visit...that later comes back to make us think, “What the heck was THAT all about...”
It goes without saying in my nursing and NP career that I have done a lot of CYA practice. Memories of instructors intoning, “if it wasn’t charted...it wasn’t done” ring in my ears. Truly, I make sure every day that my “i’s” are dotted and “t’s” are crossed. I am, as I joke with my patients, “OCD to the max” when it comes to making sure the bases are covered. I tell them, “I have to sleep at night, you know.” My all-too-frequent insomnia notwithstanding…
So it is with this background that I tell you about “Mrs. X,” A 65 year-old patient who was a nurse before retirement. In the almost 18 months in my current practice, I got to know her well. We shared stories about her family, her plans for future travel...and, oh yes, that darn pesky urinary incontinence and pelvic pressure that interfered with all of it. Couldn’t plan ANYTHING without knowing where a bathroom was at all times. Took a family trip to Disney...and spent half of the time looking for restrooms.
She had a visit with a uro-gynecologist, who deemed that she had significant pelvic floor prolapse and wanted to do surgery. I needed to do her pre-op clearance. But...wait! Her rheumatologist had mentioned bilateral carotid bruits on his consulting exam...and recommended work-up.
I heard the bruits during her pre-op visit...we talked about the risks of CVA during and after surgery. This well-informed nurse told me, in NO uncertain terms, she would NOT get a carotid duplex pre-op...her own father had stroked during his endartarectomy many years prior...and she and her sisters had to care for him in the last failing years of his life. YES...she understood her risks...but she would not change her mind. To do the duplex pre-op would change nothing...her quality of life was impacted by the incontinence, and she wanted to proceed with the surgery. She would never have surgery to correct any blockage...and despite her hyperlipidemia, she could not tolerate three different statins because of myalgias.
I cleared her medically, as she verbalized understanding of the risks of non-treatment of the bruits.
She suffered a major stroke during the 5-hour surgery, leading to a cerebral herniation due to the cerebral edema.
When I first heard of her CVA, I was dumbfounded, then blamed myself. Despite spending almost an hour with her at the pre-op visit, and her being a well-informed nurse...I felt I had failed. I SHOULD have made her get the carotid duplex (which, in the hospital, showed 99 – 100% occlusion...making the bruits apparently from collateral circulation, NOT the internal carotids). Not that she would have chosen surgery to correct it...but maybe, just maybe...she may not have had elective surgery to fix something that wasn’t...”essential.” Even if it did impact her quality of life.
I have spoken with her family on several occasions since her death. Her daughters and sons did not know that she knew of the bruits...but her sisters did...and that she had refused any work-up. From a legal standpoint, that should make me feel better…
From the personal standpoint, it is meaningless. Mrs. X, I miss you, and you will never be forgotten.
Kim Spering is a family nurse practitioner who currently works at Brndjar Medical Associates, P.C., a family practice in Emmaus, PA. Her past experience includes the fields of medical/surgical ICU, open heart/trauma ICU, labor and delivery, nursing education, nursing supervision, and as a nurse practitioner in both family practice and OB/GYN settings. She currently serves as a NP preceptor for her graduate school alma mater, DeSales University, as well as for local baccalaureate programs. She is passionate about patient education and helping patients understand that they are ultimately responsible for their own health. She also firmly believes that the public needs to be educated on the value of NPs and PAs in meeting the health care needs of the next decade and beyond. In her free time, Kim enjoys family vacations with her optometrist husband, Mark, and her two sons, Matthew and Connor.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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