Problem
Scenario: "In 1996, I had a wonderful job, friends, and family. I was living life to the fullest and had just returned from a trip to Las Vegas, where I went skydiving. Then, one day, I stepped off a curb and broke my ankle. I had surgery at a prominent Boston hospital, and everything looked fine. I was expecting a full recovery within a few short weeks, but soon after, I needed a second surgery to increase the stability in my ankle. It was with this surgery that I got the staphylococcus3 infection because of a lack of coordinated care; the staph3 infection escalated into a bone infection called osteomyelitis. This infection ate away 4 inches of my tibia fibula and half my ankle joint. Osteomyelitis is a fast-moving bone infection and is almost as difficult to eradicate as cancer. For the next five years, I endured twenty-eight surgeries consisting of bone grafts, muscle grafts and live bone transplants, and other painful surgeries. With each surgery, the physicians promised it would be the last. If the physicians had initially treated the infection with antibiotics, the outcome could have been different. The twenty-seventh surgery was going to be another excruciating live bone transplant. Two days before the surgery, the infection reared its ugly self again, this time higher up on my shin. At this point, I was 105 pounds and then unable to keep down food; I was a physical wreck. The infection and numerous surgeries had taken such a toll on me this is when I decided amputation was the only way to save my life. Four days after the initial amputation, I had to have another surgery because they failed to take enough off my leg.
During this surgery, I went into respiratory failure yet again, a total of three times in the last four years. It was five and a half years from when I broke my ankle before I took my first step, and it was on a prosthetic leg. I heard from the first step I had a brain aneurysm on my right optic blood vessel brought on by the long-term infection in my body. I'm still alive and talking, but now without the vision in my right eye with some short-term memory problems, I've been very lucky to survive all of these medical procedures caused by the hospital-borne staph3 infection. I wonder every day what other obstacle I will have to overcome; the staph infection did not ruin my life, but it has altered my life forever. Hospitals and physicians should provide coordinated care for all their patients throughout their treatment. The medical staff needs to follow strict surveillance prevention and reporting of hospital-borne infections. Had these practices had been in place, the staph infection probably would not have occurred, and a broken ankle would not have resulted in an amputated leg. Remember, anyone can break an ankle, but that's where the story should end."
Task
1. Reflect on the cascade of events from injury through 28 surgeries, three respiratory failures, and additional life-altering complications.
2. Where was the breakdown in care that led to this poor patient outcome?
3. How will this case study change or enhance your nursing care in the future?