Working in the health sector is quite challenging for the many who endeavor to take that route. In this piece, Hanan Confidence, gives an honest and emotional laden account of his personal encounter with a patient who lost her life under his care about a year ago.
With his permission, we are publishing it on this platform for you to read.
Take a read please…
I have never felt so much guilt like this before. As a nurse, I am always devastated when I lose my patients. At least, I have lost a sister before and I know how it feels. It is devastating. Sometimes, the guilt comes when you do a self-appraisal and feels you could have done A, B or C to delay the will of God. Sometimes, you find yourself saying to yourself that if you had done this or that the patient would have survived. Sometimes, you accept all of the blame oblivious of the many institutional constraints around you.
I have seen mysteries including the eleventh wonder of world but I am yet to see a mystery which mystery surpasses that of death. One moment, a patient is talking to you and in a split of a second, she can no longer say ta-da. She is motionless and does not seem to care about the earthly banalities and musings of sadness and anger around her.
As a triage nurse, I come into contact with death on daily basis. I wake up every morning with the possibilities that I have battles with the angel of death. It is always a struggle of trying to convince patients that dying is not an option that put smiles on our faces.
Triaging is sorting out of medical emergencies and giving them treatment according to urgency of their need for care. In triaging, scarce and insufficient medical supplies and equipment are deployed to assist those who need it badly. So, I guess, triage nurse is self-explanatory now.
Three days ago, the first patient who was brought to my triage bed was a pretty teen girl. Her teeth and nostril were stained with blood. She had a history of epistaxis. Epistaxis is bleeding from the nose without any physical trauma to the nose or any other part remotely linked to it. I picked a piece of sterile gauze and tidied up her mouth and nostrils.
She presented with paper white anaemia. Paper white anaemia is when a patient has a very white conjunctiva, the inner part of the eyelid. With this sign, one does not need a laboratory determination of an Hb value to order for haemotrafusion (blood transfusion). Expectedly, she was having laboured breathing, presumably as a result of low level of circulating oxyhaemoglobin. Thus, anaemia, is not necessarily, shortage of blood but less haemoglobin in the system to bind with oxygen for adequate cell breathing.
She was kept in Fowler’s position by propping up the head of the bed to facilitate full lung expansion. Nonetheless, she showed exhaustion with little activity such as sitting up. She was terribly anaemic.
Still on my independent nursing decisions, I called the oxygen man for the oxygen cylinder. Set up an IV line and notified the doctor to come and see her. She was diagnosed with epistaxis and severe anaemia. 5 L/m oxygen was prescribed to deliver more oxygen to the tissues and transxemic acid for administration to stop the bleeding. Intravenous normal saline and two pints of whole blood was ordered for infusion and transfusion respectively.
I began giving the oxygen but my patient was not cooperative. She asked me umpteen times to remove the oxygen nasal catheter from her nostrils but I continue to “deceive” her that I will remove it soon or in a few minutes. She never relent in asking if my soon or few minutes were not up. However, I explained to her that if I remove the nasal catheter, she won’t be able to breathe properly. So, she should exercise patience. As much as she might have found the nasal catheter discomforting, it was imprudent to remove it.
As I was delivering the oxygen, she instructed me at regularly intervals to adjust the head of the bed to suit her whims and comfort. I did her wishes all the time. The only whim I denied was when she wanted to change her Fowler’s position to the prone.
She was struggling to breathe, so I felt administering the normal saline will augment her blood volume and put more pressure on the heart. And whiles the blood pressure recorded as 123/90 mmHg, it was alright to withhold the normal saline. However, she could drink water. So, I allowed her to drink when she requested for it. She had finished two sachets of water and still needed more. But she regurgitated some of the water back to her bed. And her nose bleeding had resumed again. This was making the whole triage area messy. I withheld the oral fluids and began the IV fluids at a reasonable drop rate.
When the nose bleeding began, I asked the mother of the patient if they had gone to buy transxemic acid. Unfortunately, she came alone with the daughter to the hospital and relatives were on their way. So, the medicine was not ready. No one was there to go and buy it. Luckily, the bleeding stopped again after applying pressure to the bridge of the nose whiles lipting the chin up. The orifices were tidied up again and the oxygenation continued amidst calls by the patient to remove the nasal catheters.
Blood sample for grouping and cross-matching was taken to the laboratory to find a matching blood for the patient. However, per protocols, the patient relatives have to find men to come and replace the blood by “bleeding” back to the blood bank.
She was responding to the management. My conversation with her became more fluid as I stood by her following her instructions and persuading her on some dos and donts. She could now sit up and turn without exhaustion and her breathing pattern had significantly improved. I was still adjusting the bed at her will. The pulse oximeter readings had improved especially the oxygen saturation.
Suddenly, she got up of the bed, trying to get down. She said she wanted to urinate. Though she was ambulant, I didn’t want to derail the gains made so far by assisting her to the washroom. I have a particular uneasiness in passing female urinary catheter but I felt it was the best option by avoiding any activity that might deplete systemic oxygen. I instructed one student nurse around to fetch me a lubricant from the emergency ward as Foley’s catheter and urine bag was available at the triage area. I unaddressed, assisted her in modified lithotomy position, swabbed the majora and minora of the vagina cleanly with normal saline, lubricated the catheter’s tip and passed the catheter.
I explained each rational to the student nurses and gave them more information about the three unique openings: the anus, the vagina and the urethra. I faintly recollected my anatomy to feed them that the urethra is roughly 4 cm below the clitoris and the smallest in diameter to the other two openings.
About 1000 ml of urine drained immediately after the catheter was passed. A great relief came upon her. She was comfortable again in bed as evidenced by her facial expression. I was quite happy that she showed no objection to the catheterisation after explaining to her that it I will help her pass urine freely.
She was very okay now and asked me to tell her mother to give her a sachet of water. I declined. I told her that she was fine without the water because we were delivering water direct into her veins. She sat up and refused to lie down until I give her the water. But I insisted she was fine without the water. I didn’t want her to regurgitate the water back after drinking it.
She was no longer on the oxygen because she was breathing normal even though what she received could not be said to be enough to wean her off the oxygen completely. But at that material moment, she needed blood more than any other thing on planet earth.
A message came from the blood bank that the blood was ready. Thank Goodness. This is what we have all been waiting for. It was time to take her to the ward and make space for other patients who may come in needing assisted breathing or other. However, the patient insisted that she still needed water to drink. I told her that my colleague and I are sending her to a different ward and she would be given the water there. She understood me and lied down.
We assisted her gently into a stretcher and her journey to the female ward began. A colleague and I were pushing her. When we got the blood bank, we told the mother to go and inform the relatives that we are no longer at the OPD triage area but at female ward. In about three minutes, we arrived at female ward. They were aware of us. We had called earlier. We handed over her folder to the nurses there whiles verbally telling them what has been done for the patient. She suddenly started frothing at the mouth. We hurriedly unloaded her to the ward bed and she did not look like the talking interactive patient we had just brought from triaging. I called her name three times and there was no response or blink from the eyes to tell me that she could hear me but can’t respond.
I quickly started CPR. One, two, three. One, two, three. One, two, three. She jerked back to life. She is not gone yet. There is life. I said with despair. Where is your oxygen? No oxygen. They don’t have oxygen. What about ambubag? No ambubag! Of course, CPR, chest compressions without artificial ventilation is nearly almost pointless. I felt like umbrellaing her mouth with mine and blow an insane amount of air into her lungs. But her generously blood stained mouth was uninviting.
I didn’t give up. I was still one, two, threeing. But her pupils kept signalling me to stop wasting my time. I removed my phone, switched on the torch and showed it at her pupils. It emphatically told me that it no longer dances to the dictates of light. I went for the radial (wrist) pulse and it was uneventful.
I was like how? Like kaman how? The kind of how that sometimes forces a smile on your face because it is just too how. I know even on our way, we were chatting and I assured her of her water when we get to the female ward. Even at the door of female ward, there was still life. I couldn’t just think far. It isn’t that I have not seen patients die that “easily” but I have never seen patients showing so much vitality dying just “laidat”.
I called the doctor to come and confirm the death and immediately the I dropped the call, her relatives came into the ward with the blood we have longed for centuries. I quickly asked them to return it to the blood bank.
I couldn’t help saying “Ahhh” to myself every second as I replay my conversation with her just few moments before we left the OPD triage area. I felt so bad and guilty of losing her. I thought if we had not moved her to the ward, she would’ve survived. I strongly felt so. She should’ve been transfused at the triage area. I strongly felt it would’ve helped. But she was okay.
Whiles we were managing her, another patient was rushed in with asthmatic attack and had to be nebulised in the open on a stretcher – no privacy. It was one of the motivation for the transfer of the blood thirsty patient to the female ward as well. But then again, what is privacy to the dying woman? We could have left the asthmatic woman there after all she was fine.
As these barrage of guilt questions beseech me, there is one thing that makes me feel very uncomfortable for the past three days. The water I declined to give her. I am that “heartless” to deny someone her last gulp of water. Guilt knows me by my name now. Each time I close my eyes, I see her right before me asking for water to drink.
If I could turn back the hand of time, I would give her water as much as she can drink or her breath can hold. Please, go and rest in perfect peace my dear. Let me see sleep, not you, when I close my eyes. Denying you water was for your own good but if I knew that was your last sip of water you wanted, I would have yielded to your request albeit whatever.
Please don’t come asking for water when I close my eyes to sleep. Please! I feel really haunted and my heart has been so heavy with sadness. I am literally choking with guilt. I am sorry! I am closing my my eyes, please don’t come asking for water.
By the way, I need a new job!