house fire

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Mr. Serius Mulder, a 43yo man, presented by ambulance to the emergency department at St.
Florian Hospital, Melbourne, with approximately 55% burns to his body sustained in a house fire that
tragically killed his wife Sienna, child Seamus and mother Scarlet. His 16-year-old son from his first
marriage, Keegan, survived. Mr Mulder was escorted by two police officers. The ambulance
paramedic as part of their comprehensive ISBAR, advise triage nurse Kelvin that police officers would
be in attendance as they have questions to ask Mr. Mulder when the doctor says he is medically
stable to answer these. Kelvin was advised that Mr Mulder went into cardiac arrest at the scene and
was resuscitated by the neighbour Kai who is a nurse at St. Florian’s and that had it not been for her
heroic efforts, he most certainly would have died. Luckily, his airway was not compromised with
burns and whilst in and out of consciousness, he was repeatedly saying “Let me die, I just want to
die!”. About 20 minutes after arrival, Mr. Mulder grabbed nurse Kelvin by the arm, looked directly
into his eyes and stated “I want to access the new Victorian euthanasia laws and I don’t want anyone
to touch me!”. Other than saying this, Mr Mulder said nothing else and closed his eyes. Nurse Kelvin
documented this in the patient progress notes along with all other relevant clinical information.
Whilst nurse Kelvin was taking the vital signs of Mr Mulder, he again went into cardiac arrest. As the
team were doing CPR, the nurse manager Ruby read Kelvin’s documented notes and asked the
consultant Dr. Haco if “we should let him die given his requests and focus the efforts on those
wanting to be saved”. Dr Haco stated that “we will continue, thank you very much”. Mr Mulder was
resuscitated, intubated, and as transferred to the Intensive Care Unit (ICU).
***
Mr. Mulder had an unremarkable stay in ICU, was extubated and cleared for transfer to the burns
ward several days after his admission. The Police were still present and hopeful to get a statement
from Mr. Mulder as this had not been possible.
On the burns ward, nurse Hagan was assigned to look after Mr Mulder. They received a
comprehensive ISBAR handover that included that : Mr. Mulder was receiving intravenous morphine
infusion for his pain; he was due for dressing changes on first shift; he will require a bolus dose of
morphine prior to undertaking this procedure, and was on a regime of intravenous antibiotics
(Gentamycin). In the break room, nurse Hagan sought help from the burns nursing team for the
dressing change for Mr. Mulder as this procedure generally requires two people. Nurse Kai is on
shift and advised Nurse Hagan and others in the break room, that she can help and further, that the
patient is her neighbour and that she actually performed CPR for him after the fire. Nurse Farran
Hite, who was in the break room stated “why would you bother? He is an awful patient”. Nurse Kai
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responded saying, “I know right”. Nurse Kai further divulged that she often heard Mr. Mulder yelling
very loudly to his family on a daily basis. Nurse Hite said “That explains everything!”.
As nurse Hagan entered the nurse’s station, the Burns unit’s senior registrar, Dr. Electra Coutts
passed by and advised nurse Hagan that Mr. Mulder has been charted for an additional intravenous
antibiotic Benzyl-Penicillin 1.2g QID that needed to be administered immediately. This is attended
by nurse Hagan and checked at the patient bedside by nurse Kai. The medication order is
documented correctly, and the intravenous antibiotic is administered as outlined in the hospital
guidelines. Mr. Mulder recognised his neighbour, nurse Kai, and berated her for undertaking CPR at
the fire scene “You had no right to resuscitate me! I am in a lot of pain, and I want to die. I will sue
you for everything in court!”. Nurse Kai is taken aback and, as she left the room, began to cry. Nurse
Hagan advised the patient that he cannot speak to nursing staff in that way. Mr. Mulder then told
nurse Hagan, “If you touch me again I will get the police officers to arrest you!”. Nurse Hagan
observed that Mr. Mulder’s breathing was more laboured and they heard an audible wheeze. Mr
Mulder’s respiratory rate increased to 40 breaths per minute and the ECG bedside monitoring
showed Mr. Mulder’s heart rate tachycardic at 120 beats per minute. They observed Mr. Mulder
lips, face and throat showing signs of swelling and immediately activated the clinical escalation
process. Upon the arrival of the medical emergency team, Mr. Mulder was in respiratory arrest and
Nurse Hagan had commenced airway management support. Mr. Mulder was taken back to ICU for
ongoing management. That night nurse Kai was still distressed and wrote, as she does on a daily
basis, to her Facebook followers the struggles of her day. The Facebook post stated: “Hell of a day
today with the world’s nastiest patient! This patient has no right to be rude given what he did! I
regret saving his life… I shouldn’t have resuscitated him”. The post was commented on by several of
her colleagues from the burn’s unit as well as other friends and family and former colleagues.
***
Several days later, Mr. Mulder was transferred back to the burns unit for palliative care. Nurse
Hagan was again assigned to care for the patient and received a comprehensive ISBAR from ICU
nurse Col Pyre. Mr. Mulder was receiving an intravenous infusion of ketamine at 12mg/hr as well as
a morphine infusion at 10mg/hr and a dose of 10-15 mg intramuscular morphine injection every 4
hours as needed (PRN), the last dose (10mg) of morphine was given at 0800 hrs in the ICU and prior
to transfer to the unit. Nurse Col Pyre also advised that a “not for resuscitation” order had been put
in place by the ICU consultant without discussion with the patient, nor a member of his family.
Keegan was with Mr Mulder as he was transferred down. At 1130hours, on repositioning Mr.
Mulder, he groaned loudly and winced with the repositioning and Nurse Hagan observed guarding of
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the limbs. Nurse Hagan believed that Mr. Mulder was in pain and together with another nurse,
administer 5mg of morphine intramuscularly, which didn’t appear to ease the pain. At 1215hours
Nurse Hagan, together with the nurse manager Umlilo, indicated to Keegan that they will administer
a further 15mg of intramuscular morphine. Keegan objected and stated that his father didn’t
deserve to be pain free. Keegan also said, (as he is the medical decision maker and next of kin) that
if they administer the medication, then they will regret it and he will complain to the “registration
board” and complain to the ombudsman and get a solicitor to sue the nurses and the hospital for
violating the instructions given. Umlilo administered the medication anyway and Keegan stormed
out of the room and yelled “You will regret this”.
***
At 1300hrs, as Nurse Hagan started an ISBAR handover to nurse Yongin at the patient’s bedside, they
noticed Mr. Mulder was not breathing and called for the doctor to assess. Dr. Coutts declared that
the patient was deceased and asked nurse manager Umlilo to “undertake the appropriate processes
given the situation” and proceeded to inform the police officers that the patient is deceased.

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