Mr. Smith was a 60 year-old gentleman whom I met on a Thursday nightshift, seven hours following his admission to our unit. During the day, he had undergone a simple surgical procedure to insert an artificial urinary sphincter. This device is used in patients suffering from urinary incontinence. A small cuff surrounds the urethra, closing the lumen and stopping the flow of urine. There is a button that lies in the scrotum (or labia in women) that when pressed, allows water to be transferred from the cuff to a bulb, opening the urethra and allowing the passage of urine.

The entire shift was quiet and uneventful. Mr. Smith slept for nearly the entire night, only waking when I needed to perform my duties. His vital signs were taken twice throughout the night, once at the beginning of my shift, and once at 6:00am. Both sets of vital signs were completely normal. A full head-to-toe assessment was performed at the start of my shift, which showed absolutely no abnormalities. He had a dressing on his right groin where they inserted the artificial sphincter. At one point, I noticed there was a small amount of fresh blood. It certainly was not serious, or out of the ordinary for a surgical wound, but I decided to remove the dressing and replaced it with two 2X2 gauze pads. Other than the dressing change, there were no interventions needed by Mr. Smith. His pain was well controlled, he felt well, and he was excited to be going home in the morning. At 07:00 I talked to Mr. Smith one last time. He denied experiencing any pain and he did not wish to get up to the bathroom. I said goodbye and wished him good luck.

I arrived on the unit at 23:00 the following night for my next shift. I was immediately told that Mr. Smith had passed away early in the morning. At approximately 8:00am, his nurse helped him get out of bed to go to the washroom. In the washroom, he began having chest pains and experienced difficulty breathing. They called a “code 66” and began helping him back into bed. Before the code 66 team arrived, he stopped breathing. They quickly changed the code 66 to a code blue. Unfortunately, they were never able to revive him. He had died of a massive pulmonary embolism.

As we were discussing the events, one nurse pointed to a young couple and whispered, “That’s his son and daughter-in-law.” They had driven in from Saskatchewan, and were holding two hospital bags and a suitcase full of their father’s items. A nurse was helping them fill out paper work and finalize what needed to be organized. I was asked to help them find a map to their father’s apartment on the Internet so they could drive there and start on the enormous task of tying up the loose ends of his life. I was amazed at how friendly they were, and how they were able to make jokes and talk about their drive from Saskatchewan. They seemed sad, but not destroyed. I was especially distraught to learn that less than a year earlier, their mother (Mr. Smith’s wife), had died on the operating table during a surgical procedure. I could not believe the amount of pain this family must be feeling.

I printed off the map and handed it to Mr. Smith’s son, and watched as my preceptor escorted them down to the morgue where she would have to prepare Mr. Smith’s body for a viewing. I could not help but feel sad that I had said goodbye to Mr. Smith and had a cheerful conversation with him only an hour before he was pronounced dead.

My mind turned to the current night shift. I did not have time to dwell on Mr. Smith’s death. I had five new patients that I needed to prepare to care for. I sat down with my clipboard and pen and began to write down information about my current patients. I could not move forward though. Even though I tried to focus, my mind kept wandering to Mr. Smith’s death and the events surrounding his pulmonary embolism. I would find myself going for twenty minutes without writing a word on my board. At one point, I looked at the clock, it was nearly midnight, and I was not ready to start my first set of rounds with my patients.

I could not help but run through the events of the previous evening and desperately try to grasp onto something that I could have done differently. What if I had made him turn more, would he have still developed an embolism? But I had to remember that he was easily repositioning himself frequently. What if I had made him go for walks throughout the night? I reminded myself that this was not a normal practice on our unit. Could he have died because I changed his dressing? I reminded myself that there was absolutely nothing abnormal about his dressing or wound. Besides, one of the nurses had told me that the blood clot was probably forming before he came to the hospital, so there was probably nothing we could have done.

I hated that I kept ruminating on what I had charted regarding his care, knowing that what I charted “covered my ass” sufficiently. I ran through my assessments, reminding myself that there was no chest pain, leg pain, or breathing issues during my shift and I had charted the same. I felt guilty for the selfishness of these thoughts. More than anything, I hated that I kept thanking my luck that he did not want to go to the washroom at 07:00 when I asked. Perhaps, if he had, he would have died on my shift. I felt overcome with guilt, which seemed to be flying at me from every direction.

However, the biggest thought that crossed my mind was that Mr. Smith had died because he simply wanted to fix his incontinence and improve the quality of his life. I could not help but wonder if this was a worthwhile reason to risk your life. In Mr. Smith’s case, it certainly was not.

I finally managed to quell my thoughts long enough to prepare for my shift and begin my rounds. However, I was noticeably distracted throughout my shift. This was especially true when I was taking care of a patient who had been admitted to Mr. Smith’s bed only hours after he had passed away. I hated being in that room because a wave of emotion would flood me with sadness each time I stepped through the doorway. I do not feel that I did an adequate job during my shift that night. My mind and heart were not focused on the task at hand. I felt distracted and depressed. I feel that my care was “sloppy” and incomplete.

I wondered how other nurses pushed through these emotions and continued on with their duties. I especially wondered how (or if) the nurse who was caring for him when he suddenly died was able to change gears and continue on with medication administration and assessments. How do nurses experience such pain and sadness, and then continue on their day with seemingly no lasting emotional damage?

I had no answer for this question. For myself, I had to sit down after my shift (on the bus ride home) and have a long talk with myself. I had to remind myself that there are side effects to every surgery, and that deaths such as Mr. Smith’s will occur throughout my career as a nurse. I realized that when such events occur, it is incredibly easy for the nurses that cared for the patient to carry the weight of the situation on their shoulders. It is so easy for these nurses to look at their own practice and wonder if something they should/could have done would have saved the patient.

Nurses need to remember that every difficult situation is a learning experience, even if this is not the easiest (or happiest) way to learn. I know that Mr. Smith will be with me for the rest of my career. He will stand behind me every time I talk with post-surgical patients. He will whisper in my ear, telling me, “Don’t forget to remind the patient to ambulate frequently, and make sure the compression stockings are on, and tell them to reposition themselves a lot.” It is voices like these that nurses carry around with them, informing their practice. As they gain experience, more and more voices join the crowd. It is these voices that remind them that the worst can and will happen, and that it is impossible to know when. It is these voices that protect patients from potential harm. It is these voices that save lives.