Near Miss

Ever since I started working in Pediatrics over six years ago, I started out my shift with a prayer. Sometimes I'd pray in my mind as I walked up the stairs to clock in, sometimes I'd pray more formally before I left my home. My prayers were to do no harm, to remember what I've learned, to not miss anything. I think that first year I worked, I was terrified. My prayers were pleadings. It gave me anxiety to go to work. Working in Pediatrics, anything can be thrown at you. We get such a wide variety of patients. There are your normal appendectomy, T&A's, to RSV and pneumonia and bronchiolitis, to traumas and fractures, to seizures and DKA. There are jaundices babies, failure to thrive babies, overdose babies (who got into grandma's purse), overdose adolescents on suicide precautions, near drownings, ingestion of foreign body, sepsis, handicapped kids with complicated problems, lacerated spleen, head injury, cellulitis, UTI's, pertussis, meningitis (both viral and bacterial), croup, gastroenteritis, abscesses, obstructed bowel, repair of scoliosis, asthma, any kind of infection there is, and so much more. Are you catching my drift? Working on Peds, you don't know what you'll get when you walk on the floor. Like one of my patients today had a strange metabolic disease that only 38 kids have in the whole United States. I'd never heard of it before. It's a little nerve wracking for me.

This is why I pray.

This morning was no different. As I drove to work, the words passed through my mind as usual. "Do no harm, remember what I've learned, to not miss anything." We have a Pediatric Infectious Disease MD named Dr. O who just came to the area about a year ago. His office is on our floor but he floats between the pediatrics floor in Utah County and consults on patients up at Primary Children Hospital too. He's brilliant. Ever since he came, we have been getting a lot of patients right up his alley. Strange infections. He's there to make sure they heal the most effective way. He knows his stuff. I had a frail patient today with an infection that had gone to her bone called osteomyelitis. She went to surgery and came back with new orders from her surgeon. One order was to start a hefty dose of antibiotics now. I checked and saw that she hadn't received a dose in the OR or in the recovery room so I waited for pharmacy to send the dose. When it came, I checked it with the orders and proceeded to get ready to give the first dose. Just then, Dr. O came to the doorway. He had been asked to consult on the patient. What are you giving her? He asked me. I told him the name of the medication and the dose. He stopped me.

What I didn't know, and what the surgeon may not have known (based on his order) was that this particular medication could have sent this patient into renal failure due to a underlying condition she had. I was totally unaware of her condition as was the charge nurse. I realized in a cold sweat that had I gone through with the order, it could very well have shut down her kidneys. It was one of those moments when I wanted to flee. This is too much risk. This is too serious. Oh, my heart!

I thought of my prayers. I thought of Dr. O arriving right then and having that lifesaving conversation with me before even a drop infused into her line and I know it was divine intervention on behalf on that patient, me, the surgeon, and the hospital.


This is why I pray.