Behind Closed Doors: Case #5/ Maternal Death

Pt. Deteriorates-nurses fail to call Dr.-death results.

Case Information: DOCTORS HOSPITAL, 1997, L.P., INDIVIDUALLY AND D/B/A DOCTORS HOSPITAL AND :TIDWELL PARKWAY VENTURES,LLC, INDIVIDUALLY and DENITRIAPRICE, Appellants v. SANTOS HERNANDEZ, INDIVIDUALLY AND ASREPRESENTATIVE OF THE ESTATE OF CYNTHIA HERNANDEZ,DECEASED, 2009-50669 Court of Appeals of Texas, First District, Houston/ December 10, 2012

Summary: An overdue labor and delivery patient is admitted for labor inducement. Due to complications a cesarean section is required. Post procedure her blood pressure deteriorates and she dies of exsanguination.

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe nursing practice. Thank You.

(Published with permission from nursefriendly.com)

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It’s low census time at the hospital and lately you’ve been floated much more than you care to be. This time around you are being floated to a cardiothoracic surgery progressive care unit. You look at your supervisor in disbelief, objecting: “Really?” “I’m an ortho nurse, not a heart nurse, I have no clue what to do there—can’t you just send me to a med surg floor?” With a stern look, your supervisor tilts her glasses downward to look directly at you “You are not the first nurse to get floated and you won’t be the last. Just ask for help and you will be fine. Now go on before you are late for report” You gather your things and begin the treck to the other side of the hospital where it’s all things “heart.” Neato.

When you step onto the unit you ask where the charge nurse’s office is, and you are guided there by another nurse. Introductions are made. The charge nurse, Katie, thanks you for coming to help. She gives you your assignment and has assured you that every pain has been taken to keep the patients as close to med surg as possible to establish a comfort level for you. An initial glance at the kardex’s leaves you somewhat relieved. An elderly man with a UTI, a *very* elderly woman with pneumonia, an overnight observation to rule out an MI, and a patient that is slated to go down for a heart catheterization in an hour or two—make up your group for the day.  Katie reassures you that she will come and assist with the recovery of the cat-lab patient so you won’t be alone.

After morning report you make rounds, dispense medications, do assessments and give baths. The morning is going unusually well and you’re thinking “I got this.” This is a fun group of nurses who seem helpful and sympathize with the prospect of being dunked into a world you are completely uncomfortable with. The energy is good, the flow is easy. They answer questions, and share little tidbits about some of the things they do on the unit. Before long, it’s finally time for Mr. Cathlab to go for his procedure. Examining the chart, you make sure a procedural consent has been signed, that he has also signed a consent for any necessary blood transfusions, and that there is an updated advance directive. After one last set of vital signs and a quick check of the 18 gauge IV’s you inserted an hour ago (they are both flushing and pulling back just fine), Mr. Cathlab is ready to go. “Do you have any questions, any concerns?” You ask. His blue eyes are warm and happy “Not a thing! Let’s getter done!” He’s been the rockstar of your group of patients. A deep booming voice, southern drawl, silver hair, piercing blue eyes, and happy, easy energy make up this rare find. To top it off, a big cowboy hat sits proudly on top of neatly folded blue jeans on the counter, the worn down boots at his bedside. He gives you a wink “see you soon darlin, watch that hat for me, it’s always brought me good luck!” You laugh and reassure Mr. Cathlab that his hat is in safe hands.

Its 1PM when the cath lab nurses roll Mr. Cathlab down the hall and you take this opportunity to catch up on charting, I/O, vitals, medications, and orders. He is supposed to come back in an hour.  But he does not. So you continue to get caught up on piggyback antibiotics, vital signs, I/O’s, and charting. Fifteen minutes into the third hour your concern grows, prompting you to call down to the cathlab, inquiring about your patient. “We’re on our way up now.” They advise you. Just then, a lady calls out for help going to the restroom so you race into the room to assist. The bathroom trip turns into more of a strange odyssey, and when you have broken free from the grips of her “2^nd Uncle Louie at the last family reunion” anecdote you check to see if Mr. Cathlab has arrived. He has. But there are no nurses to be seen, the cathlab nurses are gone. You call the charge nurse’s phone for expert assistance but she is in helping with a combative patient who has kicked a nurse. Katie says she will be there as soon as she can. You check the nurses station for any of the other nurses to assist you but everyone is in patient rooms except for the docs.

Looking around the room you spot a pink sheet taped to the patient’s white board with handwriting on it that is difficult to read. The only thing you understand is that Mr. Cathlab’s vital signs were 100/70 with a heart rate of 100 before he arrived. “OK this isn’t bad” you think. You grab a vital sign machine and take a set to see how he is doing: 98/60, heart rate 100. Reviewing the pink information sheet you find what looks like a “scribbled” dose of Fentanyl that had been given prior to his arrival back to the unit. His pressure is a little low, but you figure he must be relaxing from the pain medication. “How do you feel?” You ask. He turns his head over to you, winks, smiles, and says his back hurts a little more than usual but then again he’s always had back problems. Mr. Cathlab is alert, oriented, answering questions appropriately; his skin is pink and dry. You make a mental note to ask one of the nurses to print a telemetry strip and interpret it for you.  Smiling back, you rub his shoulder reassuringly, and give him the call light with instructions to call if his pain gets any worse of he feels any different. “Will do darlin,” he responds, before nodding off to sleep.

An hour later you sneak in and take another blood pressure. This time it is 90/60 and his heart rate is 110. You wake him up and ask how he is doing. “Fine, darlin, just thirsty. Can you get me some orange juice?” You oblige, reminding him of the doctor’s instructions about the bed rest. “You can get up a little after 7PM.” “I’m bein’ good sweetie, don’t want the nurses upset at me! Can you get me somethin to pee in? I feel like I have to go so bad, it’s makin my lower belly hurt, like there’s pressure, and my low back is really hurtin from layin flat like a board for so long, can you get me something for that?” You nod, hurrying out to get Mr. Cathlab both a urinal and a shot of IV Fentanyl to help with his pain. “This should do it my pretty friend!” He waves you away “go take care of the other sickies I’m fine!” You turn to leave, but something catches your eye–His skin appears to be glistening, so you stop for a moment and place a hand on his forehead. “Are you feeling hot?” You ask. “Nah I just gotta pee real bad so scoot!” He commands. After leaving the room, you go check with the nurse who has been watching his heart monitor. She says Mr. Cathlab has been tachycardic with a heart rate in the one teens  since his arrival back to floor, nothing she considered unusual.

     Shift change arrives and you are relieved to be giving report to an ortho nurse you recognize. She will be taking over your group of patients for the night. Report is uneventful and you advise the new nurse that Mr. Cathlab can get out of bed to walk now since the pink sheet said 7:15PM. You pass it on to her so she will have it for reference. After sharing your last vital signs of this very pleasant man you prepare to go home. For a float day, it’s been one of the best you’ve had. As you are cleaning your workstation and gathering your things, a code is called over- head. It’s Mr. Cathlab’s room. “What? No way. That can’t be right.” You say to yourself. At the moment, you’re bent over picking up your bags from under the telemetry monitor desk. You drop them, slowly inching yourself  upward to see the part of the monitor with his name on it. Your heart sinks into your gut. You may not be a cardiac nurse, but you know what ventricular fibrillation looks like…and it’s right there in front of you. Panic sets in, what should you do? Even though you are officially “off” do you go back to help? You decide to run back, and find his room full of people: The code team, the cardiologist, a lot of nurses. The glimpse you do manage to get of the patient doesn’t look good. His skin looks mottled and his eyes are still open and staring upward. You notice his well- worn boots now sit neatly next to the cowboy hat on top of the carefully folded blue jeans, your eyes become fixed on them, clinging to the hope that if you wish hard enough he’ll wake up and ask for his hat….But no.

The team performs a quick turn of Mr. Cathlab’s body to assess his back and you see a large amount of ecchymosis over the right flank and the lower back. “Looks like a retroperitoneal bleed guys” you hear the cardiologist say. He goes on to explain “We had problems with persistent bleeding during his cath earlier, but I thought we had it stopped. Does anyone have his vital signs for the past few hours?” The code resumes. You go back to the desk, digging the report sheet on Mr. Cathlab out of your nurse bag. Reviewing the vital signs you took earlier your stomach takes a dive worthy of the Olympics—straight to the ground into a pool of nausea….the blood pressure had been trending down and his heart rate had been increasing—signs of hypovolemia, a hemorrhage. Stunned, you lean against the nearest wall for support and slowly slide down…. “I should have caught it…” you say to yourself. “…I should have caught that…….” Forty minutes go by and you haven’t dared to move. You wait, and wait, and wait, and it seems like forever before the code team comes up the hall, and the nurses return to the station. A hand reaches down; touching your shoulder reassuringly “your guy didn’t make it.” Nodding, you stand up, clutching the report sheet in your hand, and head back to the patient’s room to talk to the cardiologist. You’re pretty sure this is going to be the longest night of your life.

The Real Thing

On August 26, 2007 Cynthia Hernandez, a Spanish speaking only patient, was brought to Doctors Hospital of Texas  for a planned induction of labor. At 41 weeks and 4 days of pregnancy, Cynthia was overdue. It was noted via her advance directive that she was a Jehovah’s Witness and against blood transfusions. However, a 2006 medical power of attorney revealed that Cynthia would “consider the use of blood fractions upon later discussion.” An interesting side note: “The religious organization of Jehovah’s Witnesses numbers more than 7 million members worldwide, including 165,000 members in Germany. Although Jehovah’s Witnesses strictly refuse the transfusion of allogeneic red blood cells, platelets and plasma, Jehovah’s Witness patients may nevertheless benefit from modern therapeutic concepts including major surgical procedures without facing an excessive risk of death.”(Habler, 2010)

On August 27, 2007 her labor induction began at 2:00PM. Later that evening, at 7:45PM, RN Pierce took over Mrs. Hernandez’s care. Pierce was a labor and delivery nurse. At 9:45PM Cynthia’s Dr., Dr. Piegari, decided to deliver the baby via cesarean section due to complications the patient was having throughout the inducement. A baby girl was delivered at 11:18 PM without complications.  Josselyn Naomi Hernandez weighed 10 pounds, 1 ounce. RN Pierce continued to care for Mrs. Hernandez in the PACU. The anesthesiologist on the case discharged Mrs. Hernandez from his care at 11:29PM. During the stay in PACU, RN Pierce noted 200 ml of blood in Mrs. Hernandez’s Foley bag. Her blood pressure at that time was 98/54 with a heart rate of 100. (Pre surgery vitals were 118/74, 84).  Dr. Piegari was not notified of the blood pressure noted by RN Pierce. Pierce’s documentation was difficult to interpret because it reflected three different assessments that appeared to contradict one another: “dark red blood via Foley, scant vaginal blood loss, and no active bleeding noted.”

Mrs. Hernandez was eventually transferred to a general floor and would be cared for by RN Clamato. At 1:10 AM RN Clamato recorded a blood pressure of 98/52 and a heart rate of 102. Again, Dr. Piegari was not notified of the vital signs. At 2:10 AM RN Clamato rechecked Mrs. Hernandez’s blood pressure. This time she obtained a blood pressure of 75/50 and a heart rate of 111. RN Clamato initiated a telephone call at 2:20 AM when Mrs. Hernandez’s blood pressure further deteriorated to 68/48.  She would be transferred back to the labor and delivery unit at 2:40 while Dr. Piegari was en route to the hospital. He had scrambled another surgeon to assist him, and a nurse anesthetist. Mrs. Hernandez was rushed into surgery at 04:05 AM. The emergency laparotomy surgery began at 4:20 AM and ended at 05:20 AM. According to Dr. Piegari’s notes, “four liters of blood were found in the abdominal cavity, and there was bleeding from the left lower uterine segment that was ligated and sutured.” Dr. Piegari also noted that hemostasis was achieved during the surgery. Post operatively, Mrs. Hernandez was taken to the ICU, but 30 minutes after her arrival she went into cardiac arrest. She died on August 28, 2007 at 6:52 AM.

Questions for Discussion

1. What would have been the very earliest point a problem could have been identified? Who could have caught it?
2. Should the patient have been transferred to a general floor? Why or why not?
3. What part(s) of the “nursing process” may have been overlooked in this case?
4. For you labor and delivery nurses—what mitigating factors could have contributed to this situation occurring?
5. For you labor and delivery nurses—do you perceive barriers in your efforts to provide best care? If so, how do you try and work around them?
6. While knowledge of normal vital signs and abnormal vital signs are taught to nurses regardless of specialty do you think RN Clamato, on the general floor, should have been given an OB patient fresh from a C-section? Why or why not?
7. Outside of calling the physician sooner, what could both RN Pierce and RN Clamato have done to intervene in a timelier manner?
8. How do you feel about the Advance Directives versus the Power of Attorney as they relate to the blood products?
9. Do you think if a discussion had taken place between the nurse and the patient about the blood products prior to inducement Mrs. Hernandez might have lived? (remember she received no blood products in surgery)
10. Do you feel it is a nurse’s duty/responsibility to review these documents and talk to the patient about them prior to procedures? Why or why not?
11. Can you identify possible breaches of standard of nursing care in this case? This would include anyone from the charge nurse, the nurses involved in the care of the patient, or the physician
12. There was  mention of a language barrier in the court documents; do you think this may have been a mitigating factor in this case?

Outcome

On October 21, 2010 The Court of Appeals of Texas, First District in Houston reaffirmed its initial judgment in favor of Mr. Hernandez and the estate of Cynthia Hernandez. The resolution between the parties involved (any financial reward and/or terms) was not disclosed in public records.

Discussion

Before I go any further, I’d like to offer my respect to labor and delivery nurses everywhere. At the beginning of this piece I wrote from the perspective of a medical surgical or cardiac nurse because I have no clue what it is like to work a normal day on a unit such as yours. I don’t know what the flow of a day is like, the standards of care, the “culture or “norms.” I do not know how an induction proceeds, how emergencies are handled, or what goes into your clinical decision making—out of respect to all of you, I kept my discussion of any OB issues limited to the case itself as I was writing from a more objective frame of mind rather than a subjective one. I will try to do the same in following discussion. My approach is one that is inquisitive in nature not just for my learning purposes but for the learning of others.

    While researching for this article I learned some statistics about cesarean sections published in “Obstetrics and Gynecology”:  “The risk of postpartum death was 3.6 times higher after

Cesarean than after vaginal delivery (odds ratio 3.64 95% confidence interval 2.15– 6.19). Both prepartum and intrapartum cesarean delivery were associated with a significantly

increased risk. Cesarean delivery was associated with a significantly increased risk of maternal death from complications of anesthesia, puerperal infection, and venous thromboembolism.”

(Demeux-Tharaux 2006) I didn’t know these things, but I assume my labor and delivery colleagues are far more up to speed in matters involving babies and moms.

      Specialty aside, I identified a few items that trouble me about Mrs. Hernandez’s case. My concerns, by the way, are considered universal in our profession and not exclusive to any type of nursing. These days it is common practice to check a patient’s chart to make sure that some kind of advance directive is present. When a patient identifies him/herself as a Jehovah’s Witness the first action on my part as their nurse is to confirm they do not, under any circumstances, want blood products. I not only make a note in the computer, I verbally notify the physician myself, and pass the information on in report. What a patient tells me in that moment I am with them supersedes anything that was signed by them 2 or 3 years ago. I inform the physician right away of any changes that conflict with the advance directives so he/she can meet with the patient and explore the patient’s desires further. If the patient is alert, oriented, and able to make their own decisions, their wishes pertaining to the healthcare they would like to receive is respected, supported, and every effort is made to update the advance directive paperwork to reflect this. I do not believe in, nor do I ever engage in sensitive and ethically charged conversations with my patients when they are obviously not in a position to participate or a language barrier is present. (There seems to be rumors indicating otherwise).

In Mrs. Hernandez’s case I noted conflicting preferences about blood products and a gap in time between documents. I believe that a discussion between her, a translator, the physician, and a nurse prior to induction *might* have yielded her permission for blood products to be given in the case of an emergency —-or—-the physician could have offered alternatives to transfusion. Could these issues have been discussed and worked out prior to induction in an office setting where there is more time and less urgency? It was established that Mrs. Hernandez was not able to understand, speak, or read English. Herein lies a potential health literacy problem and a language barrier that places yet another obstacle between her and the rights she had as a patient.

“Health literacy” is not a new term. In fact the concept has been around since the 1980’s.(NAI, 2012)  Simply defined, it means “people’s ability to read and understand health information and includes the capacity to obtain, process, and engage in basic health information and services and subsequently making suitable health decisions.” (Hay, 2010) Though simple in its earliest uses, the concept of Health literacy has evolved significantly over the years, encompassing a host of much more complex ideas and suppositions.  In a nutshell, it’s the Learning Assessment I know we all do when we first meet a new patient. Could this be one of the reasons that the blood pressure wasn’t addressed for so long? Was Mrs. Hernandez able to express symptoms such as “nausea, dizziness, weakness, or heart racing?” Did she understand signs of trouble and when to call for help? Did she understand what the call light was for and how to use it? According to the case information there were no accommodations made to close the communication gap. (translator, translation phone, or RN matching)

Language and cultural diversity make a big impact on both the quality and quantity of care an individual receives. The lack of attention to transcultural nursing as an approach to the holistic care of this mother and child is clearly apparent. “Transcultural nursing is essential in daily nursing practice…(it)  has become a key component in healthcare and a requirement for today’s practicing nurses because of the soaring multicultural phenomenon occurring in our American population. According to the U.S. Bureau of the Census (2000), over 30% of the total population or one out of every three persons in the United States is comprised of various ethnicities other than non-Hispanic whites.” (Maier-Lorentz, 2008)

***For further reading on the origins of transcultural nursing please explore Leininger’s Culture Care Theory (1978)***.

      I have never been a charge nurse (thank God), but I do understand that part of their responsibilities is to pair nurses with patients based on several things: they both speak the same language, are of the same culture, the nurse’s experience or skill set is appropriate for the patient’s care needs, personalities, and of course—the rapport between nurse and patient. In Mrs. Hernandez’s case I wonder whether either of the nurses possessed the assessment skills and experience to care for a patient such as her. For instance, isn’t there a fundus to be assessed and, at times, massaged? Doesn’t the nurse have to monitor the characteristics of the lochia?  Unit Charge Nurses are tasked with the job of “setting nurse to patient assignments, typically focusing their assignment efforts on what was recognized as the most important workload measure, patient acuity.”(Acar, 2010)  Could there have been an oversight in assigning an appropriate acuity to Mrs. Hernandez? Was the labor and delivery nurse a new grad lacking the skills or experience to care for this type of labor and delivery patient? Was she overloaded with patients? Was she working overtime due to short staffing? Was the nurse on the “general floor” even remotely qualified to take care of post cesarean section patients? Perhaps she herself was a nurse floated to the general floor and ended up caring for a patient type she had never encountered before. “The nurse patient assignment (process) is specific enough to identify and match characteristics of the nurse and patient that may affect patient safety outcomes.” (Allen, 2012) With this in mind, could there have been some oversight in the communication between the charge nurse from the labor and delivery unit and the charge nurse on the general floor about the type of care or resources Mrs. Hernandez would require? Could there have been a failure, on behalf of the charge nurses involved, to assess the skill sets of the nurses assigned to care for Mrs. Hernandez? Why would Mrs. Hernandez, post cesarean section, be assigned to a general floor to begin with? Furthermore, why was she separated from her infant?

No one knows what happened that night but the nurses and the doctor involved. This piece is not about singing the now overplayed “they should have they could have” song or casting blame. That solves nothing, and it’s not my place. However, scholarly inquiry is a must as there are numerous questions to ask about the tragic course of events that took place the night of August 28^th, 2010. They could, should, lead to a thorough root cause analyses so that at each point a break down in care or communication occurred a cause is discovered and a plan put in place to prevent a recurrence. Our current culture, for the most part, is not a “just culture.” Rather we seem to enjoy taking the easiest route to problem solving– we assign fault to a person or persons by pointing fingers and ostracizing them rather than embracing a systems approach to error resolution. This approach isn’t some novel new trend; in fact, its roots go way back to 1919: “Greenwood and Woods (1919) carried out the first statistical studies of accident proneness. They hypothesized that certain individuals experienced accidents because of a particular susceptibility, which was attributable to their personalities. It has since been demonstrated that the context of their work had a clear bearing on their conclusions (Lawton & Parker 1998).Greenwood and Woods_ report, submitted to the government of the day, was not based on studying men at their physical peak – but on very young or old men who were operating machinery with ever-increasing speeds in repressive high-risk conditions, against the clock. Their findings conveniently supported a potent strategy for many factory managers: dismiss those workers who were thought to be inherently flawed while ignoring any responsibility for providing safe working conditions. Findings of this kind probably helped lay the foundations for focusing blame on those proximal to the error, or what is known as the _sharp end.” (Armitage, 2009)

We are taught what is both normal and abnormal in nursing school. Regardless of our nursing specialties, nurses are all held to the same standards when it comes to protecting the ABC’s. (airway, breathing, and circulation).  ABC’s are the universal needs in every patient population. Nothing should ever stand in the way or come before vigilance.  I have worked in facilities where the nursing priority seemed to be Facebook, Pinterest, Zoosk, Twitter, texting, email, or internet shopping while crucial drips ran dry. (And yet these “nurses” still work there) This article is a good dose of reality for those of you who think that looking at your patient one time at the beginning of the shift and relying on a patient care assistant to tell you whether or not they are still breathing throughout the shift is Nursing. Mrs. Hernandez’s case was a tragic one. Although it involved a labor and delivery patient, the events and lessons are applicable to any patient on any unit.

If it’s been a few hours since you have done your “hourly rounding” and you are caught up to speed on your friends’ Facebook updates, your email, and sizing up who is jockeying for the charge nurse position that just opened up…. now might be a good time to, ahem, ….see for yourself if your patients are still breathing.  Why not take it a few steps further….change that dry bag of Dobutamine and get a blood pressure or two–yourself.

  The formula is  really rather simple….

Hi Tech, Hi Touch, Hi Thinking = Good patient outcomes

 

 

Works Cited

DOCTORS HOSPITAL, 1997, L.P., INDIVIDUALLY AND D/B/A DOCTORS HOSPITAL AND TIDWELL PARKWAY VENTURES,LLC, INDIVIDUALLY and DENITRIAPRICE, Appellants v. SANTOS HERNANDEZ, INDIVIDUALLY AND ASREPRESENTATIVE OF THE ESTATE OF CYNTHIA HERNANDEZ,DECEASED, 2009-50669 (Court of Appeals of Texas, First District, Houston December 10, 2012). Retrieved September 16, 2012

Acar, I. (2010, May). Dissertation. A Decision Model For Nurse to Patient Assignment. Kalamazoo, Michigan: ProQuest, LLC. Retrieved September 16, 2012

Allen, S. (2012). Dissertation. The Nurse-Patient Assignment: Purposes, Decision Factors and Steps of the Process, 1-102. South Carolina: ProQuest, LLC. Retrieved September 16, 2012

Armitage, G. (2009). Human error theory: relevance to nurse management. Journal of Nursing Management, 17, 193-202. Retrieved September 16, 2012

Chichester, M. (2008, October). Cesarean Delivery Is Rising: Implications for Care for the Perianesthesia Nurse. Journal of Perianesthesia Nursing, 23(5), 321-334. doi:doi:10.1016/j.jopan.2008.03.010

Demeaux-Tharaux, C. C.-C. (2006, September). Postpartum Maternal Mortality and Cesarean Delivery. Obstetrics & Gynecology, 108(3), 541-548. Retrieved September 16, 2012

Habler, O. (2010). Der Anaesthesist, 59(4), 297-311. doi:10.1007/s00101-010-1701-2

Hay, L. (2010, May 26). In Practice. Perspectives in Public Health, 130(105), 105. doi:DOI: 10.1177/17579139101300030202

Maier-Lorentz, M. (2008). Transcultural Nursing: Its Importance In Nursing Practice. Journal of Cultural Diversity, 15(1), 37-43. Retrieved September 16, 2012

N.A.I. (2010, December 1). Pt. Deteriorates nurses fail to call Dr. death results. Retrieved September 16, 2012, from Free Library: http://www.thefreelibrary.com/Pt.+Deteriorates-nurses+fail+to+call+Dr.-death+results.-a0247158405

N.A.I. (2012, January 13). Understanding and Health Literacy:. Perspectives in Public Health, 132(25), 25. doi:DOI: 10.1177/1757913911431043

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