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Nursing is a profession of many roles and responsibilities, over the years I have

experienced many teachable moments good and bad. We tend to remember the worst, we

remember the near misses and mistakes. Again, teachable moments and opportunities to make

things better, to promote safety and sustainable change. In the beginning of my career I did not

know this, I do now and for situations such as one I am going to share.

As a recovery room nurse for the Cardiac Catheterization lab I learned to manage patients

of variable acuities through staffing constraints. In the Fall of 2013 census was not anticipated to

climb until November but the patients came early. Staffing was slow to follow and adjust. One

situation and patient in particular will never be forgotten and I was taught a lesson. The patient

was a 63 year old Native American female admitted to the hospital for chest pain and shortness

of breath. She had a low level troponin elevation of 0.16; this bought her a diagnosis of non st

elevation myocardial infarction or NSTEMI and a trip to the cardiac cath lab. She had a past

medical history of hypertension, diabetes, dyslipidemia and polio, she was also wheelchair

bound. She was brought to the recovery room after her procedure in which she received one drug

eluding stent to the right coronary artery. During the case she received sedation, as well as

300mg Plavix and 325mg ASA. She also had an angiomax infusion running per protocol and was

stopped at 1830. She had two access sites, one being a right radial site with an intact trans-radial

band and a 6 french femoral sheath to the right groin. The femoral sheath was due to be pulled at

approximately 2030, two hours after completion of the angiomax infusion.

The patient had been admitted to the inpatient cardiac floor from the emergency

department of a regional hospital. At the time the hospital had two cardiothoracic surgeons and

about 12 cardiologists. The cardiac catheterization lab had approximately 18 scheduled cases that
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day and the majority of cases were outpatient procedures, the patient in question was added on a

the end of the day.

The cardiac catheterization lab was and remains divided into three sections: the pre op or

the prep, the procedural lab and the recovery. The prep and recovery are staffed exclusively

with registered nurses. There is charge nurse for the prep and recovery but that charge nurse

leaves at 1700. The recovery room had approx. 6 patients upon arrival of the 63yr old female at

approximately 1800. It had been a busy day and all patients, with the exception of the inpatients

were due to be discharged that evening. There were three recovery nurses. The nurse that

received report from the procedural nurse for the patient was due to leave at 1900. There were

two other nurses, including myself that evening and we both were on call starting at 2000, after a

full 12 hour shift.

The nurse that had been caring for the patient reported off to me at the end of her shift.

An assessment was completed, the patient had her daughter at the bedside and both were kept

updated and notified of plans for the patients recovery including that the patient had a femoral

sheath in place and that it would be removed after 2030. Per routine in the recovery room the

patients daughter was prepared and told that while the pull and pressure was done that she

would be asked to step in the waiting room and as soon as the procedure was finished she could

come back to the recovery room and be with her mother and accompany her back to her inpatient

room. Both agreed to the plan of care and it was explained to both the process of a sheath pull.

There were three total patients in the recovery room at the time. One patient was in the process

of being discharged and the other was scheduled to be discharged at 2100. At 2100 there were

two patients left in the recovery room. It was decided that my coworker would pull the sheath as

I had had manually pulled two sheaths back to back. The plan was that once hemostasis was
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achieved the other patient in the recovery room would be walked and discharged. The family for

the patient would be brought back to the recovery room and report could be called for transfer

back to the cardiac floor after a short observation. At approximately 2100 the sheath was pulled

and a manual hold started, after 15 minutes and hemostasis was thought to be achieved all

pressure was removed. The patient immediately developed a hematoma and manual pressure was

restarted by the nurse that pulled the sheath. The hold was difficult and the hematoma continued

to expand into the inguinal fold and down the anterior inner thigh. Pressure was maintained by

my coworker despite the expanding hematoma. I medicated the patient for pain and placed a

Foley catheter just in case a full bladder was the culprit behind the hematoma. After a few

minutes of being unable to stop the expansion of the hematoma the cardiologist was paged to

notify of the issue. The other patient was still in the recovery room and he was told that as soon

as staff could be with him he would be up walking and could call for his ride for discharge. The

house supervisor was called to ask for back up, unfortunately the house supervisor was involved

with another patient situation, so the ICU charge nurse was called and came down to the

recovery to assist. He took over the hold as the nurse that pulled the sheath had been holding

pressure by that time over half an hour. In the meantime the cardiologist called back and was

notified of the situation. He gave instructions and advised to call back if the situation did not

improve. After approx. 15 minutes and no sign of relief he was called back again and spoke to

the nurse that pulled the sheath. At that time the cardiologist decided to come in to evaluate the

patient. Now that there was an additional person in the recovery the family was notified that

there was difficulty after pulling the sheath and the patients husband was called to come to

waiting area so that he could also be informed of his wifes condition and speak to the

cardiologist. The family was told that their loved one was still being worked on and they would
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be updated as they waited. Ultrasound was called for a bedside ultrasound to locate the area of

the bleed, to adjust the site of pressure and to verify if there was a pseudo-aneurysm. During this

time the patient was made aware of what was going on but because of the severity of condition

decisions were made mostly on her behalf. Her nursing care, because of the emergent situation

was tailored to her medical needs. The cardiologist and house supervisor arrived and the on call

vascular surgeon was called and came to evaluate the patient, he opted out of the case but the

cardiovascular surgeon was available to see the patient and came and evaluated her as well. It

was decided that the cardiovascular surgeon would take the patient to the operating room to find

the bleed and attempt to close it. I remember accompanying the cardiologist to the waiting room

as he spoke with the family and notified them of the situation and what the plan was. Consent for

surgery and anesthesia was obtained. Because pressure was still being maintained on the sheath

removal site the family was not brought back to the recovery room. During that time the patient

was prepped for surgery and the operating team came took report and transported the patient to

surgery. The patients family was taken to the surgical waiting room, and they were told what

was being done and that the surgeon would speak to them as soon as he was finished with their

loved one. The other patient was walked and discharged home in stable condition. Charting and

debriefing was done between the two on call nurses. The patient was out of surgery and in the

post anesthesia care unit or (PACU) within an hour after leaving for surgery.

It was later discovered that because the patient had polio and poor muscle tone the

arterial stick did not have enough support from the tissue to close. She subsequently needed two

units of blood but was discharged a few days later and made a full recovery. The initial plan was

to complete tasks and get patients up and out what occurred was unexpected. Ultimately, the

patient did receive care that she needed but it was imbedded in chaos and complications. Out of
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sheer necessity staff did team together and did what they could to provide the best care that was

possible at the time.

Retrospectively, it is clear that the staff did notify the family and keep them informed but

never asked them or the patient what they needed or valued. Those decisions were decided upon

by medical staff. The family was not brought back to see their loved one. Nor were they given

the option, as she was still being worked on. If staff had asked the patient if she wanted to see her

family she may have felt as if she were part of the decision making process. She may have felt

out of control and that may have helped her to not feel so helpless. At the time the objective was

to get her to surgery as quickly as possible. It was thought that maybe her family would have

made a scene or slowed down the process, that question will never be known. It is only after the

fact that important questions were posed. What if the patient did not have as good of an outcome

as she did? What if she died during surgery and the last time she could have spoken to her family

she was not allowed to.

Many lessons were learned as well. The patients care could have been more

individualized with respect to what she wanted and valued in her care. She could have been

asked what she wanted as far as seeing her family during that time or not. In regards to the

system of care if the house supervisor had known the staffing issues and condition of the

recovery room that night maybe he would have been available for assistance or offered

suggestions regarding care. If the recovery room had an additional nurse that was staffed later in

the evening there could have been an additional person to speak with the patient and the family

while the medical needs of the patient were addressed. A lesson in providing optimal patient

outcomes could have been preparedness and staff education. Had we known more about patients

with muscle disorders and the likelihood of complications from those disorders maybe the sheath
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would have been pulled differently perhaps using a clamp. Maybe the hematoma would have

been less severe or not developed at all. After that event I remember two more patients with polio

come through the recovery room that year, those patients did not have complications partly

because of the lessons learned that night.

As nurses we all have the unique opportunity and obligation to improve not only our

practice but healthcare. This is not done by focusing exclusively on ourselves or by tearing other

nurses apart. This is done by inspiring each other to learn more, by engaging each other to do

more, and by learning from our mistakes to make things better.