I have had a long career in nursing and have cared for countless patients. I remember so many of them for all sorts of different reasons, but a few really linger in my mind. Why? Probably because they touched me and taught me. I remember Amy well because of the many lessons I learned from her.
The history
Amy Lee was a 63-year-old Chinese-American who worked as an office manager at a small manufacturing company in a large city. She had been at the company for 35 years, hired by Mr. Henry when his company was just getting started. Amy was single, never married. As a first-born, she was somewhat of a disappointment to her parents because she was not a boy. Five years after her birth, the desired male child arrived, but Sam was born with Down syndrome. Moreover, Amy’s mother suffered postpartum hemorrhage with a subsequent hysterectomy, so the hope for a male to carry on the family name and traditions was lost. For Amy, however, Sam’s loving disposition was a source of happiness throughout his 16 years of life, until he died from cardiac problems associated with his condition.
While attending a local college, Amy started dating and fell in love with a young Caucasian man. She kept the relationship a secret from her parents, because she knew that dating outside her culture would not be accepted. Even in big cities, it is hard to be invisible. A family friend saw Amy and her boyfriend together and promptly reported what he had observed to Amy’s parents. She ended the relationship.
When Amy was 28, her father died from a cerebral aneurysm, leaving her responsible for overseeing her mother. Although Amy’s mother was physically and mentally healthy, she spoke little English and was quite dependent on others, especially Amy, for providing a sense of security and well-being.
It was at this time that Mr. Henry hired Amy. To take the focus off the disappointments she had experienced in life, she poured her soul into her job. Luckily, Amy did have a small group of girlfriends who she enjoyed meeting occasionally for dinner and a movie. She also had a secret passion: golf. It was the one thing her father had taken the time to share with her. Unless the weather was plain awful, Amy could be found every Saturday morning at the local driving range and golf course.
Change, the only constant
Time passed, and Mr. Henry retired, leaving the company to his son, little Henry. Now, little Henry, having grown up spoiled by all that his father had worked so hard to provide, was much more interested in fancy cars, two-martini lunches and running with the “beautiful people” than what was best for the business. Consequently, Amy was demoted from office manager to senior accountant, while Linda, a young, good-looking clerical worker with no college degree, was promoted to Amy’s old position.
One week after her demotion, police and emergency medical services were called to a thoroughfare in the city where a woman—Amy—was sitting in a car with the engine on, unresponsive to the people who stopped to assist her. Although her vital signs were stable, the paramedics could not get any response. Her limbs were flaccid, and there was no eye contact, no sounds, no movement. She was placed on a gurney and transported to the nearest hospital, which happened to be a very fine medical center, offering some of the best care in the city.
A perfect storm
At the hospital, Amy was triaged and diagnostic tests were performed. When nothing conclusive was discovered, she was admitted to a monitored neurological floor for observation. Unfortunately, a perfect storm was brewing.
Amy was admitted on the Friday evening of a holiday weekend, so staffing was shorter than normal and admissions higher than normal. Over that weekend, one crisis after another occurred and, to attend to the most urgent needs, the nurses found it necessary to keep changing priorities. On Saturday, Amy’s mother and a friend of hers from the neighborhood showed up and sat quietly in Amy’s room, never questioning the care—or lack of it—with anyone. They had no idea what was going on and, because Amy was always the one who took charge in situations, no one took charge.
Unfortunately, the physical therapist on duty that weekend was Walter. Walter was a bright, middle-aged man who spent his energy figuring out how to get out of work. Because the nurses were so busy, no one noticed that Walter never gave Amy the range-of-motion exercises that had been ordered.
Days passed, and the first responsiveness from Amy came in the form of groaning. When the regular Monday nursing staff came on duty, an aide noted a large, reddened warm spot on Amy’s left calf. She alerted her charge nurse, who alerted the resident on call. Unfortunately, Ed, the resident, was much more interested in brain tumors than reddened calves, so he ordered only elevation and warm packs. He never saw Amy. On Tuesday afternoon, the attending physician made rounds with her residents and was immediately concerned about Amy’s leg. Treatment for a clot was initiated, but it failed. On Friday, Amy had a BKA—below-the-knee amputation—of her left leg.
The importance of a diagnosis
One week after losing her leg, Amy was transferred to Psychiatry. That is where I met her. She was alert, oriented times three (oriented to person, place and time), talking, but guarded. All of the information about what had transpired came from other staff, not from Amy. What did come from her medical record was the correct diagnosis of acute psychosis with catatonic features, which explained her physical and mental status when found in her car. What was never said or written was that there was no indication of any vascular problem—other than what we, the health care team, gave her by putting her in a bed and not moving her for days on end. So here was this woman, already traumatized by little Henry, who now was missing a leg because of us.
Making conversation with Amy was not easy. Her short answers did not invite further talk. I respected that and asked her if I could tell her a story. She nodded affirmatively. I told her the story about the farmer and the donkey, with its underlying message of resilience and hope. When my shift ended, I told Amy I enjoyed meeting her and would see her again in three days, when I was scheduled to work again.
From bad to worse
The elevated temperature began that night, after I went home. Fluids and IV antibiotics were ordered, but Amy’s temperature kept rising. Blood cultures were taken, and she was transferred to a step-down unit. Two days later, she died from sepsis. When I returned to work, the other staff members gave me the news. Totally dumbfounded, I grieved over the loss of this poor woman who should never have died at this time, in this way. I kept asking myself, “How could this have happened?”
Little Henry sent a huge splay of flowers to the funeral, along with a note stating how sorry he was that he was unable to attend. Mr. Henry, now in poor health, was truly unable to attend, but his wife came on his behalf. Amy’s mother, supported on both sides by family friends, looked like a deer in the headlights. Yes, I saw them all, because I, too, was there. It was the only funeral of a patient I have ever attended. I may have done it more to help me deal with all of the events than for Amy’s sake. For me, Amy seemed to represent all of the patients who trust us and whom we let down.
Take-aways
I almost left nursing after this episode. I was a relatively new RN and so distraught by all the mistakes that never should have happened. I mean, we were all scared to death by our nursing instructors about the possibility of killing a patient, but we tended to believe it would have been related to violating one of the five rights of patients and not something as complex and scary as this situation, which involved so many disciplines.
The failure of the nurses to meet Amy’s needs felt the worst, however. As in the case of Lewis Blackman many years later, Amy died surrounded by the best medical technology and most highly educated health care workers in the world. I didn’t leave nursing, but I have stayed scared ever since. Maybe that is a good thing.
Here is what I learned from Amy:
Stick to the basics. If staff members had done simple range-of-motion exercises, this horror could have been avoided.
Speak up. If you do not have time to really tend to your patients, tell your charge nurse; call the house supervisor, the administrator on call or whomever you need to call. Tell them that the care you are able to provide is insufficient and that more staffing must be provided. Insist on safe staffing.
Be vigilant. Most problems start small. Pay attention to any changes. If you have the “feeling” that something is not right, odds are, it isn’t.
Look at the big picture. Consider all systems when evaluating your patients—respiratory, GI, vascular, etc. I once knew of a patient who starved to death because members of each discipline were looking only at their piece of the patient, and no one realized that the patient had not had any real nutrition for 10 days. But that is another story. RNL
Kendall Nuss Altheimer, LCSW, CCM, RN, is director of education and consulting at Kaiser Permanente Medical Center in West Los Angeles, California, USA.
