That one time a doc almost killed a patient

Out of nowhere, as I was walking into the hospital today, I was reminded of a surgeon that I knew back in CA.

I may have told this story before.

I was a newer OR nurse and I was assisting with a manipulation of a shoulder.

The surgeon did the manipulation and then barked for the medication.

‘What medication?’ I asked, innocently.

‘You know the medication, the epi, to inject this joint.’

I had been an OR nurse for about three months as I recall.

I dutifully went to the pyxis and pulled out an entire bottle of epinephrine.

I knew it was not correct.

But no one else corrected him.

Not the scrub tech.

Not the anesthesiologist.

It didn’t even phase the PACU nurses when I pulled out a ginormous bottle of epi.

Okay, no one was going to help me.

The surgeon was waiting, impatiently, for a syringe of medication and a needle.

I put the epi in my pocket and walked back to the room.

He put his hand out.

And I refused.

He looked at me as if I was less than nothing.

Me? Denying a surgeon.

He looked at the anesthesiologist who was maintaining the airway, probably hoping I’d get a move on.

He looked at the scrub who was leaning against the wall. They don’t have a role in manipulations.

I pulled out the brown 20 ml bottle of epinephrine and I showed it to him.

‘This is not the medication you think it is.’

‘Never mind,’ he growled, hand still out.

‘This is epinephrine. This is a medication that is given during codes to restart someone’s heart. I will not be giving you a 20 ml syringe of this. It would kill the patient.’

He blinked and looked at me and then at the bottle and then back to me.

‘What can I give then?’

I pulled the second bottle out of my pocket and showed it to him. ‘This is marcaine with epi 1:200,000. This is what you want.’

He made a gimmee motion with his fingers.

I drew it up, put a new needle on it, and handed it to him, telling him in a closed loop communication although he had just seen me draw it up, ‘This is marcaine 0.5% with epinephrine 1:200,000.’

No further mention was made of his nearly catastrophic medication error.

No further mention was made of how it was good that I stood up to him.

Nurses don’t do this kind of thing for recognition.

We do it to keep the patient safe.

And that was the first time I stood up and defied a surgeon.

It has not been the last.

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