Nora Walsh was a young nurse who lived in a two-story house with her parents, in Pittsburgh,
Pennsylvania. She had two jobs - a full-time job in the Emergency Department and a part-time
job as a nursing tutor. She took pride in her love of science and decided to name her
two small Pomeranians - Pen and Vanco, after 2 types of antibiotics - Penicillin and Vancomycin.
One day, after wrapping up a tutoring session, she went straight to the Emergency Department
to do a night shift.
In the early morning hours of her shift, a patient - Parviz Elagin - was brought in by
his husband. Parviz’s skin was covered in hives, his face was swollen, and he was having
difficulty breathing. Dr. Arturo Reyes screamed from the other side of the room: “He’s
got severe anaphylaxis! Let’s grab the crash cart - we need the Endotracheal tube, epi,
and IV fluids! Nora, I need your help on this!” Nora left her coffee and rushed over to get
the crash cart.
A few seconds later, she was at the bedside quickly opening up the drawers to get access
to everything and rubbing her hands together with hand sanitizer. “Here you go doc,”
Nora said as she passed the endotracheal tube to Dr. Reyes. “Nora… I need you to…”
Dr. Reyes was trying to tell her something while he was struggling with the intubation.
It was clear - the patient’s larynx was too narrow for this size of the tube. After
several failed attempts, Dr. Reyes pulled out the tube and said, “Nora, I need you
to get me another tube - We need a smaller diameter. ” Nora rushed. A few minutes later,
the intubation was complete and everyone in the room took a collective deep breath. But
Parviz was still critically ill and his blood pressure was starting to drift down - a worrisome
sign of shock. “Give him 2 milliliters of epinephrine,” Dr. Reyes ordered. Nora looked
at Dr. Reyes in a strange way, like something was clearly wrong, and asked: “Are you sure,
Dr. Reyes?” “Yeah, let’s do this, he needs epi in his system. And if he doesn’t
respond then I want you to give him 2 more.”
Nora grabbed the vial of epinephrine in the cart which had a concentration of 1:1000,
and delivered 2 milliliters which works out to a dzose of 2 milligrams. A couple of moments
later, the patient began to experience chest pain and heavy breathing. His blood pressure
shot up fast - 200/120. Nora and Dr. Reyes looked up the ECG monitor and saw the same
thing. "He's experiencing severe tachycardia. We need to do something!" Nora shouted. Unfortunately,
the rapid change was too dramatic and within moments the patient died.
Dr. Reyes stared in shock and realized that he had said 2 milliliters, but that he had
assumed that the vial of epinephrine had a concentration of 1:10000. He wanted to give
a dose of 0.2 milligrams rather than 2 milligrams. He had ordered Nora to give ten times more
epinephrine by mistake. Nora and Dr. Reyes explained what happened to Parviz’s husband
Elon who was stunned and horrified.
Within a few months, a lawsuit was brought against the hospital and both Nora and Dr.
Reyes were named specifically because they ordered and delivered the medication that
ultimately led to Parviz’s death from the epinephrine overdose.
Now - to rewind this back - let’s imagine that Nora had precisely asked Dr. Reyes about
the epinephrine dose, rather than the volume of the medication. She could have repeated
the dose out loud when she was noting it in the patient’s chart, and also when she was
about to inject it. This way, Dr. Reyes would have probably noticed the high dose that he
ordered, and he would have reduced it to 0.2 milligrams. The moral: Request medications
in terms of amounts rather than volumes. Verbal orders should be written down and repeated
back and confirmed - even in an emergency.