Last week I experienced the worst day of my career. Actually, it rivals the worst day of my life.
It was my first week back from vacation. My old kitty, Meow Meow, had been in boarding during the holidays. When I got her home, she didn’t seem quite right. She wasn’t eating or drinking very well for a couple of days, and she was weirdly clingy. Although I chalked it up to stress, I decided to bring her into the hospital for blood work and IV fluids.
It was an unusually slow morning. Technicians and assistants were puttering around, chatting. There was only one extensive dental procedure lined up, so I decided to get the ball rolling with Meow Meow. I examined her, drew blood, collected urine, and placed an IV catheter. I asked one of our technicians to prepare a bag of LRS. She hung up the bag, and proceeded to get a cage ready. I looked up to see a full bag of LRS, with fluid sitting in the drip chamber, all ready to go; or so I thought. I grabbed the line which had been draped over the hook, connected it to her port, and opened the crank. Something wasn’t right about the way it dripped; I looked at the technician holding Meow Meow and we realized simultaneously, the line wasn’t primed. She swiftly pulled it out, but it was too late. Meow Meow got a line full of air. She died. Almost instantly. CPR failed. Her tiny little body couldn’t survive that.
I was shattered. I screamed and wailed over her dead body in the treatment room. How could this have happened? How could a bag have been spiked, a drip chamber filled, and the line not primed? Why didn’t I check it? Why MY cat? Why didn’t I get that bag ready myself, as I normally do? Why did I bring her in? I should have left her at home. She probably would have been fine.
My husband and I took her to the crematorium. I cried for a long while, clutching her wee body tightly in my arms. I apologized to her for allowing this mistake to happen, to take her life. I thanked her for all the joy she brought me through the years and hoped that she enjoyed her life with us.
I took a couple of days off work to grieve and lament. I requested the owners of the practice call a meeting to review protocol; to remind the team that careless medical practice is a recipe for disaster; to bring some justice for Meow Meow. I came back to find out that nothing was said or done. Instead, it was swept under the rug, like so many other things have been in the past. Oh, and Meow Meow’s test results were normal too.
Meow Meow died because of sloppy work. I wish I could tell you there was a reason this distraction occurred; that we were super busy and it happened in a moment of chaos. However, there is absolutely no excuse for it.
It is my hope that in sharing this story, I can remind those in the veterinary community that vigilance must always be practiced. Systems must be in place to prevent errors. We must always check each other’s work. We must constantly remind ourselves that this is serious work, as lives are hanging in the balance. We can do better. Some of us need this reminder more than others.
It is my hope that Meow Meow’s story will save a life.
Editor’s Note: This piece broke my heart, as a pet lover and as a colleague. The author’s admonition to learn from her mistakes is a loving testament to her beloved pet. I also hope as a community we know the importance of being gentle with ourselves when mistakes happen, which they, unfortunately, do to us all.
