#this is the long post i said i'd reward myself with btw

[andhumanslovedstories]

A while ago at work, I had a patient whose condition rapidly deteriorated during my shift, which I believed at the time was due to me not monitoring certain therapies closely enough. Essentially patient had parameters that their oxygen saturations should be between 88-92%. The patient was on supplemental oxygen via a nasal cannula, and was having oxygen saturations of 95% or more. The patient later became lethargic, confused, and hard to rouse. The patient was in hypercapnic respiratory failure, where they essentially were not exhaling enough CO2, the waste product of respirations. Patients who have oxygen parameters of 88-92% tend to be COPD patients, and I'd been taught where giving them too much oxygen can result in CO2 retention.

We ended up having to call a rapid response on that patient who needed to go on the bipap (non-invasive ventilator) to help them breathe effectively, and I went home from that shift feeling certain that I killed this person. That I had triggered a terminal decline that the patient would never recover from.

(Perhaps some context here: my grandfather went into hypercapnic respiratory failure and then died within a few days. Maybe he would have passed either way, I think probably he would have, but the respiratory failure was the moment his decline started accelerating. After he went hypercapnic, he was non-responsive from that point on.)

I called in sick to my next shift because I couldn't face going in. I spent the day thinking about what I'd done, what my moral obligations were, how do you atone for something when you cannot reverse the effects of the original error, and how paralyzed by shame I felt. What did I owe the patient? What did I owe the family? What did I owe myself? How many times had this happened before and I just didn't know because the decline happened after my shift ended?

It was a productive if unpleasant day of trying to sincerely examine myself and the things I'd done wrong without flagellating myself. It'd be almost easily to complete condemn myself and to stop nursing because I'm a Bad Nurse than it would have been to acknowledge the many steps that led to this patient outcome, only some of which I had a hand in. But this was my patient. They were my responsibility. What was the right reaction to have? What should I be feeling? In the course of doing my job, I caused harm to someone I swore to take care of. I still think that I am a thoughtful, hardworking, and compassionate nurse. I don't think the hospital would be better off if I quit. But I hurt someone.

I thought a lot about how this outcome happened, came up with steps to prevent it in the future, and found a new commitment within myself for continued learning. (If you've got a timeline of my particular fixations, this is about when my determination to go to grad school began.) I also thought about how much shame was making me sick. When my patient started declining and I realized the effects of my actions and inactions, one of my first thoughts was genuinely, "Everyone's going to know what I did." It was thought with absolute horror. I'd hurt someone and everyone was going to know it. They were going to know I was bad at my job and bad as a person.

And I was struck by what an unhelpful emotion that was. How much it made me, if only for a moment, tell NO ONE what was going on and what I believed to be the root cause. That it'd be better to let the decline continue rather than intervene because if I intervened that'd be admitting that I'd done something wrong. I didn't listen to that voice that told me to hide what I'd done, but I instantly understood the power of it.

There's this thing called the Compass of Shame which is about the different ways people handle their own feelings of shame--they avoid the shame, they withdraw from themselves and others, they attack others, they attack themselves. I know my own reactions to shame and try therefore not to go with my gut instincts, which are always to say I'm an irredeemably bad person and no one can know about this and if anyone does not about what I've done wrong, I deserve literally whatever punishment they could give me. I've had to learn I can both have failed to complete my responsibilities and still not deserve to lose my job or my flunk this class or give up on college or lose all my friends. But there is something appealing about masochistic shame. Like you can prevent others from judging and punishing you if you sufficiently judge and punish yourself. You'll still be a wretched monster, but no one else needs to know that.

That's actively dangerous for patients, who are the victims of healthcare errors, and it doesn't help prevent future mistakes if we are too ashamed to talk about what happened and why. We'll just keep fucking up in the exact same ways because no one else told us how they'd fucked up that way in the past and here's how we've changed the process because of that. I therefore have an ethical obligation to not internalize shame when I make mistakes at my job. I have tried to remember that while also trying my best to not make the same mistakes twice.

And then a week later, I was sent back to the same floor with the patient who'd declined on my watch. Because I'm a float RN and therefore don't have an assigned unit, I go to different floors every night (occasionally multiple floors on the same night). I see patients for 12 hours and then almost never see them again. Since I was back on the floor, I girded myself and went to go visit the patient, who to my surprise was alert and upright and about the same as I'd seen her at the beginning of my shift before they'd gotten bad. I said hi and asked how the patient was doing, and the answer was that patient was doing about the same as they'd been doing for the last month.

This was not good news for the patient, who was still medically complex, still dealing with an extremely difficult to address condition, but they were also not in the ICU, dying, or dead which is what I'd feared. And with the new knowledge that the patient was, if not okay, than at least stable as ever despite my actions, I could look back on that shift and see it differently, namely that this patient kept continuing to go into hypercapnic respiratory failure with or without oxygen. And then I looked into what I thought I'd been negligent about before and found that the scholarship on it was more complicated and divided than I'd thought. That the mechanism of action that I thought was driving the hypercapnic respiratory failure was in fact waaaaaaaaaaay more complicated than just over oxygenation, particularly in this patient who had a number of muscular abnormalities that made much more of an impact on ventilation than the oxygen would have. And while I still had to improve my practice, upon more reflection I could no longer say there was a direct one to one of my actions and the patient's decline.

I felt simultaneously forgiven, absolved, and humbled. I cannot describe to you the almost sheepish relief that rushed over me. Nothing that bad had happened. What did happen was only ambiguously my fault.

There's a power fantasy to shame sometimes, that you are uniquely bad and that your actions have monumental consequences. My actions on the job can have monumental consequences, but usually they are little things, little cares, little turns, little med doses, little therapies, little steps, little tasks, little jobs, little kindnesses or little cruelties that help a patient move forward or which hold a patient back. I'm there for 12 hours and never again. I can do a lot in that time, but I'm not gonna cure them and I'm probably not going to kill them. It's a relief, and it's a strange disappointment. We want to be important, even in bad ways.

While I can certainly fuck things up for patients, while I can certainly kill patients or traumatize them or withhold care or misuse my position, while I can do all those things, I don't actually have that much power over life and death. Everything that goes wrong isn't my fault. And sometimes something is your fault and nothing really happens except a few people have a bad night and you try not to do it again. I think that last bit is the most important part. I still should have titrated her oxygen down. I'm more careful about that now. I'm trying not to fuck up in the exact same way. I'll find exciting new ways to fuck up, and then I'll learn from those too.