Submitted by a friend of a friend. It is from a cancer patient's on-line journal. This did not take place at our hospital. It could happen almost anywhere, I'm guessing.
In our hospital, this situation would have prompted a "Trigger" because the low oxygen saturation is a Trigger standard, as is "marked nursing concern." Would our Trigger team notice the root cause?
I thought I'd wait until I'd left the hospital to recount this story. One evening, my friend was visiting and the nursing assistant came in to take my vital signs. My level of blood oxygenation (02 saturation) was lower than normal, and so she called the nurse, who turned up the level of oxygen I was getting through my nose from 3 liters to 6 liters. It didn't seem to help. Then the Reiki lady came to give me my "sample" Reiki treatment (which I liked). Afterward, my oxygen level was no better.
The nursing shift changed and the new nurse was concerned about my "sats". She called a doctor, who couldn't see anything wrong, but was concerned, since I clearly should not have been "desatting". She gave me an EKG. She gave me another EKG. She called another doctor. She ordered a portable chest X-ray. She gave me a nebulizer treatment. This all lasts until nearly midnight.
By this time, I am getting anxious (no matter how hard I try to breathe in deeply through my nose and out through my mouth, I can't seem to get the sats up). So she is also giving me ativan. She suggests to the nurse that she call respiratory therapy and ask them to bring up a mask, so that I can breathe in through both my mouth and my nose. The respiratory therapy guy comes, but before he gives me the mask, he firmly attaches the oxygen tubing to the oxygen source on the wall. It had come loose. No one else checked.
So, I had two doctor visits, two EKGs, a chest X-ray and a nebulizer treatment because it wasn't plugged in.