211) Calcium Bath Bulletin

January 29, 2008
Tuesday

El Milagro: I’m here on time at 4 today and… they’re running about 30 minutes late. On my way back out to the weighting room, I stop by Dr. Rowder’s drive-by team, who are standing in the middle of the floor, not clearly visiting with any patient. I ask, “So, what’s the story?” to Jennifer the Dietician. She replies, “They had you on the wrong bath.” Dr. Rowder continues, “We’re gonna check your calcium today.” Sherry the Social Worker inquires about how I feel so I report that I have been puffy since Saturday; I walked out of here on Saturday weighing more than when I came in; and I have felt bloated since. Then I ask Dr. Rowder, “So, is this something I need to learn to check myself to make sure it’s done right?” He shakes his head and replies, “No. Its highly unusual for that kind of thing to happen. You don’t have to check it.” I feel like responding back with a list of the things that have been mistakes since I have been here, but realize they need to get back to their drive-bys and it isn’t really my turn to be talking to them, since I’m not even in a chair yet. (I probably will follow the advice of Bill P and be more aware of these things)

I scoot outa there and do a few errands and return to find a chair waiting for me. I weigh in at 80.7, even though I have concentrated on minimizing my fluid intake since Saturday. That has been easy since I get immediate feedback when I look at my puffy hands that I can’t really clasp together… like the Nowicki Doughboy. I was in Tyler yesterday doing a training and kept myself to one cup of coffee and one glass of water through the whole thing.

Kim the Nurse comes over and listens to my chest and feels my puffy hands. She listens to my story about Saturday and acknowledges that they probably gave me the wrong bath. My bath should be a “1 K 2 Ca” bath and Kim points it out on my poop sheet on the clip board and on the bottle on the floor in front of the dialyzer. She continues that probably what happened was they gave me a "0 Ca" bath, which resulted in the dialyzer filtering out all the calcium in my system without replacing any. When she checks my standing BP it is 163 / 83, so I am clearly upset about this whole thing. She and I determine that we want to try to take most of the gain off this session, so she sets the machine for taking off 5.4 Kgs.

I settle in and down and pretty soon Dr. Rowder drives his cart over and asks, “Is there anything else we need to talk about?”. I say “Yes. Is there a way to ensure this kind of thing doesn’t happen again… since it was not a really fun deal.” The Doc doesn’t have a succinct answer to that one but he does apologize and assures me that the event was unusual. In my little brain of brains, I wonder how many times mistakes really occur and if they do have internal procedures for correcting them. I hate to think that Amanda the Tech was the culprit of this… and when I think back, I actually don’t remember her being the one who set up the bath. Many times the tech who is cannulating me isn’t the one who sets up the machine, which includes getting the bath set up. In the past (see Post # 20, June 2006), when staff gave me the wrong dialyzer, the parties involved were suspended for a day. I wonder what they do for this kind of thing, if anything. Perhaps this is a question to bring up at the next PAC Meeting with the administration. Since there seems to be nothing else to discuss with Rowder and the team, I just acknowledge his apology and reflect that it pissed me off… to which Jennifer the Dietician throws back, “Wimp” as they walk away.

I’m thinking she’ll be back soon to share that that comment was a joke.

I listen to NPR and doze a little and check my BP after awhile and it is down to 120 over something, so I am calming down. One of the things that continues to gnaw at me is that on Saturday, even when staff realized I was on the wrong bath, they didn’t come up and acknowledge that their behavior led to my discomfort. Instead, I was in a situation of thinking that it was something to do with me. Somehow I had done something that led to my bottoming out. It seems to me that as soon as they figured out I was on the wrong bath they should have told me and then told me that they were doing everything they could to make it better. Now, it is true that in the state I was in I was not feeling well enough to have a long discussion about the whole event. But, I would’ve like to hear that it was their problem not my problem. I also would like to get a look at whatever they wrote in my record to document this event. Did they write something like, "Mr. Nowicki's calcium was low so we blah blah blah" which doesn't really identify that they gave the wrong bath... or, did they write something like, "we goofed and gave the poor patient the wrong bath, which caused his extremities and lips to tingle like a mild electric shock was pursing through them." Maybe I can get someone to share with me the documentation that was put in the record. Maybe it's really not that big a deal and I should count my blessings and go on with my life.

Oh well. There are always things that can improve in any enterprise. And, I know that many of the staff are doing the best they can and in the long run I do appreciate the care they take of me. So, who am I to gripe? It could be worse.

By the end of the session I am feeling better and happy to get outa there into the cold Austin night and head home to the family. A note on the cold night: I came in today in short sleeves with no jacket cause it was over 70° out and then on the news I found that the temperature is dropping by about 30°. So, I wrap myself in my Mexican blanket and head out to the truck. It reminds me of many years ago when I first decided to keep a down jacket behind the seat of my truck because of the wild weather shifts out in West Texas. As I am shivering on home, my memories go back to the time that Susie and I pulled off the road in our little VW square-back to sleep overnight and the next morning we were snowed into the car, with drifts up over the roof. We had to dig out and then slide back down the mountain on icy treacherous roads. That was in April in the mountains of northern New Mexico. What a great memory.

Notes: In at 80.7 and out at 75.8 Kgs.