Midnight Fiasco

Mireya is doing well.  The results of her blood culture will take at least 48 hours.  She continues to get rounds of fluids and antibiotics.  In the past, Mireya has had a reaction to one of the antibiotics and requires pre-treatment with Benydryl.  Benydryl tends to make her tired, so she was able to rest pretty well through the night.  Our nurse came in to ask me about Mireya's Hickman Catheter.  She said notes from the ER stated they 'accessed Mireya's port' which confused her because she knew Mireya had a Hickman Catheter.  Within about ten minutes, I was greeted by two very concerned doctors explaining to me a serious mishap that occurred while we were in the ER.

The ER staff gave Mireya one dose of her antibiotic and noted it was administered through her port (a port is a line accessible under the skin).  When lines are accessed they need to be flushed and heparinized.  Heparin is a blood thinner used in varying quantities to prevent clotting in the line.  I specifically had to correct two doctors and one of our nurses because they kept referring to her hickman as a port.  Our ER nurse asked me how much heparin we used at home?   I gave her the amount per line and she flushed Reya before we were sent up to the Main Hospital.

The type of line you have determines the amount and concentration of heparin received.  Mireya was mistakenly given a higher concentration of Heparin and double the dose she should have received.  I was mortified and infuriated...so basically your telling me I'm having a Dennis Quaid moment?  If you don't recall the story when Dennis Quaid's twins were born, they were given lethal doses of heparin in a California hospital.  The Quaid's ordeal was due to a similar issue with administering doses of the incorrect concentration of heparin.  A report has been initiated downstairs to investigate how this occurred.  Both of the doctors were very apologetic and equally concerned about the serious medical implications this had for Mireya. 

Mireya's platelets are very low. Platelets are responsible for clotting the blood. The major issue with low platelets is falls or hitting the head and having a bleed situation where the body is not able to clot the blood appropriately.  Mireya's platelets had to be rechecked and her blood clotting functionality measured. The Doctors were uneasy and urged for an immediate transfusion to boost her platelet count. We were trying to hold off on all transfusions unless absolutely necessary.  The results of the test showed her platelets had decreased by 4k.  At that point a transfusion was inevitable.  I was surprised her platelets were wiped out at that rate in such a short period of time.  Her blood clotting functionality was okay and it did not appear that she would have any adverse affects.

I thank God for his hand of protection and for our Nurse who recognized the inconsistency of notes and the actual situation.  I know there is so much going on down in the ER, but this incident could have been avoided.  It's a lesson for everyone, one I talk myself through some days....stop and focus on the task at hand so we can give our full attention to what is before us, instead of already mentally being in the next place. Thank you Lord that our Warrior Princess slept like 'Sleeping Beauty' through it all and she woke up ready to face another day with a beautiful smile on her face.